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MDIS #2545
Summary of Benefits
January 1 through December 31, 2012
Medicare
Supplement Plans
Dental Plans
Vision Plans
Life Insurance Plan
State Flower, Indian Blanket
State Animal, Buffalo
Option Period Guide
Plan Year 2012
State Bird, Scissored-tailed Flycatcher
E7848_G1000You should have already received a schedule of retiree Option Period meetings. If you plan to attend one of these meetings, please bring this Guide with you.
Enrollment Information
♦ Your Option Period Enrollment/Change Form is being mailed in a separate security envelope. When you receive your form, review your personalized information in the upper right-hand corner. This section lists the coverage you will have January 1, through December 31, 2012, if you do not make changes to your coverage this Option Period.
If you DO NOT WANT to make changes:
♦ No further action is necessary. You do NOT need to return your Option Period Enrollment/Change Form. OSEEGIB will automatically carry your 2011 coverage over to 2012.
♦ You will not receive a Confirmation Statement from OSEEGIB. Keep your Option Period Enrollment/Change Form as proof of your insurance coverage.
♦ If you live in a long-term care facility, such as a skilled nurse facility or nursing home, do not allow your facility to enroll you in another Medicare Part D plan. Enrollment in another Part D plan will end your Part D coverage through OSEEGIB and cause your premiums to increase.
If you WANT TO make changes, your enrollment form is due by December 7.
♦ The following resources are also available to help you decide on your coverage:
• This Guide • Online Provider Directories • Plan Formularies
• Plan Websites • Customer Service Representatives
♦ Review the premium rates and plan changes for 2012.
♦ Enroll in only one Part D plan.
♦ Check the appropriate boxes on your Option Period Enrollment/Change Form to make changes.
♦♦If you decide to change Part D plans, you must complete and return a separate enrollment application to the plan you select, as well as return your Option Period Enrollment/Change Form to OSEEGIB. Contact each plan to request an application. See Help Lines on page 41.
♦♦If you already have Part D coverage through another employer or union plan, you must select one of the HealthChoice Medicare Supplement Plans Without Part D.
♦ Return your enrollment/change form by December 7.
♦ Review your Confirmation Statement when you receive it to verify your coverage is correct.
♦ If your coverage is listed incorrectly, please contact OSEEGIB Member Services as soon as possible. See Help Lines on page 41.
If you have questions or need more information, please contact OSEEGIB at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D
$332.54 per enrollee
HealthChoice Employer PDP Low Option With Part D
$273.02 per enrollee
HealthChoice High Option Without Part D
$383.34 per enrollee
HealthChoice Low Option Without Part D
$323.82 per enrollee
UnitedHealthcare Senior Supplement High Option
$398.76 per enrollee
UnitedHealthcare Senior Supplement Low Option
$357.63 per enrollee
DENTAL PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
HealthChoice Dental
$30.20
$30.20
$25.18
$65.32
Assurant Freedom Preferred
$28.83
$28.67
$21.50
$57.80
Assurant Heritage Plus (Prepaid)
$11.74
$ 8.86
$ 7.60
$15.20
Assurant Heritage Secure (Prepaid)
$ 7.20
$ 5.98
$ 5.20
$10.38
CIGNA Dental Care Plan (Prepaid)
$ 9.26
$ 6.06
$ 7.08
$15.32
Delta Dental PPO
$33.64
$33.62
$29.26
$74.04
Delta Dental Premier
$38.36
$38.36
$33.38
$84.46
Delta Dental PPO — Choice
$15.06
$34.18
$34.44
$83.60
VISION PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
Humana/CompBenefits VisionCare Plan
$6.76
$5.06
$3.57
$ 4.46
Primary Vision Care Services (PVCS)
$9.25
$8.00
$8.50
$10.75
Superior Vision Plan
$7.14
$7.10
$6.72
$13.80
UnitedHealthcare Vision
$8.18
$5.79
$4.59
$ 6.98
Vision Service Plan (VSP)
$8.76
$5.87
$5.62
$12.64
LIFE PLAN
From $5,000 to $40,000 $1.88 Per $1,000 Unit
Age Rated Life – Cost Per $1,000 from $41,000 and Up
< 30 ---------- $0.03
45 - 49 ------- $0.10
65 - 69 ------- $0.51
30 - 34 ------- $0.03
50 - 54 ------- $0.17
70 - 74 ------- $0.87
35 - 39 ------- $0.04
55 - 59 ------- $0.27
75+ ----------- $1.35
40 - 44 ------- $0.06
60 - 64 ------- $0.31
DEPENDENT LIFE
$0.94 Per $500 Unit, Per Dependent
Monthly Premiums for Medicare Eligible Members
Plan Year January 1, 2012 - December 31, 2012
These rates do not reflect any contribution from your retirement system.MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D
$332.54 per enrollee
HealthChoice Employer PDP Low Option With Part D
$273.02 per enrollee
HealthChoice High Option Without Part D
$391.01 per enrollee
HealthChoice Low Option Without Part D
$330.30 per enrollee
UnitedHealthcare Senior Supplement High Option
$398.76 per enrollee
UnitedHealthcare Senior Supplement Low Option
$357.63 per enrollee
DENTAL PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
HealthChoice Dental
$30.80
$30.80
$25.68
$66.63
Assurant Freedom Preferred
$29.41
$29.24
$21.93
$58.96
Assurant Heritage Plus with SBA (Prepaid)
$11.97
$ 9.04
$ 7.75
$15.50
Assurant Heritage Secure (Prepaid)
$ 7.34
$ 6.10
$ 5.30
$10.59
CIGNA Dental Care Plan (Prepaid)
$ 9.45
$ 6.18
$ 7.22
$15.63
Delta Dental PPO
$34.31
$34.29
$29.85
$75.52
Delta Dental Premier
$39.13
$39.13
$34.05
$86.15
Delta Dental PPO — Choice
$15.36
$34.86
$35.13
$85.27
VISION PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
Humana/CompBenefits VisionCare Plan
$6.90
$5.16
$3.64
$ 4.55
Primary Vision Care Services (PVCS)
$9.44
$8.16
$8.67
$10.97
Superior Vision Plan
$7.28
$7.24
$6.85
$14.08
UnitedHealthcare Vision
$8.34
$5.91
$4.68
$ 7.12
Vision Service Plan (VSP)
$8.94
$5.99
$5.73
$12.89
Monthly COBRA Premiums for Medicare Eligible Members
Plan Year January 1, 2012 - December 31, 2012
Agency policy states that one person must always pay the primary member premium. When a dependent spouse, child, or children are insured under a particular benefit, but the primary member did not keep that benefit, one person is always billed the primary member rate.
Monthly Life Insurance Premiums for Surviving Dependents
Surviving dependents
of current employees
LOW OPTION
$2.60
STANDARD OPTION
$4.32
PREMIER OPTION
$8.64
Spouse
$6,000 of coverage
$10,000 of coverage
$20,000 of coverage
Child (age 6 months to 26)
$3,000 of coverage
$ 5,000 of coverage
$10,000 of coverage
Child (live birth to 6 months)
$1,000 of coverage
$ 1,000 of coverage
$ 1,000 of coverage
Surviving dependents
of former employees
$0.94 Per $500 Unit, Per DependentSection I
Plan Identification Information and General Information................................. 1
Section II
HealthChoice Medicare Supplement Plans....................................................... 9
2012 Annual Notice of Change......................................................................... 10
Section III
UnitedHealthcare Senior Supplement Plans.................................................... 25
Section IV
Dental and Vision Plan Options....................................................................... 33
Help Lines............................................................................................................ 41
TABLE OF CONTENTS
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S. Section 1301, et seq; 17,000 copies have been printed at a cost of $0.61. each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
A text version of this Option Period Guide is available on the OSEEGIB website at www.sib.ok.gov or www.healthchoiceok.com. This Guide is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH at 1-405-521-3514 or toll-free 1-800-523-0288. TDD users call 1-405-521-4672. The information contained in this Guide is only a brief summary of the listed options. All benefits and limitations of these plans are governed in all cases by the relevant plan documents, insurance contracts, handbooks, agency Rules, and the regulations governing the Medicare Prescription Drug Benefit, Improvement, and Modernization Act. The Federal Regulation at 42 C.F.R. § 423 et seq. and the Rules of the Oklahoma Administrative Code, Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations, or exclusions of any plan.Section I
Plan Identification
and
General Information
1
2012 Plan YearPlan Identification Information
Plan Administrator
OSEEGIB
3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Medicare Supplement Plans
Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8780 or toll-free 1-800-752-9475; Fax: 1-405-717-8942
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Website: www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Health, Dental, and Life Claims Administrator
HP Administrative Services, LLC, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
PO Box 24870, Oklahoma City, OK 73124-0870
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
HealthChoice Pharmacy Benefits Manager
Medco, 24 hours a day, 7 days a week
With Part D Plans: Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D Plans: Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Website: www.medco.com
HealthChoice Certification Administrator
APS Healthcare, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
PO Box 700005, Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121 or toll-free TDD 1-877-267-6367
UnitedHealthcare Senior Supplement Plans
Customer Service, Monday through Friday, 9:00 a.m. to 9:00 p.m., Central time
PO Box 6072, Cypress, CA 90630
Toll-free 1-800-851-3802 or toll-free TYY 1-800-851-3802, ext. 711
Website: www.UHCRetiree.com
Medicare
Customer Service, 24 hours a day, 7 days a week
Toll-free 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048
Website: www.medicare.gov
Website Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: www.socialsecurity.gov
2012 Plan Year
23
2012 Plan Year
General Information
The benefit information provided in this Option Period Guide (Summary of Benefits) is only a brief description of each plan’s benefits. If you need additional information to help you make a coverage decision, contact each individual plan. See Help Lines on page 41.
New! New! The Annual Option Period Ends December 7, 2011 New! New!
Medicare has changed the dates for the Annual Coordinated Election Period! This year, you have from October 15 until December 7 to make changes to your coverage. Changes received after the December 7 deadline cannot be accepted.
2012 Plan Changes
There are changes to the plans and plan benefits being offered for 2012.
♦♦Most plan changes are indicated by bold text in each plan’s benefit chart
Plans Participating in 2012
Medicare Supplement Plans:
♦♦HealthChoice Employer PDP High and Low Option Medicare Supplement Plans With Part D
♦♦HealthChoice High and Low Option Medicare Supplement Plans Without Part D
♦♦UnitedHealthcare Senior Supplement High and Low Option Plans
Dental Plans:
♦♦Assurant Freedom Preferred
♦♦Delta Dental PPO
♦♦Assurant Heritage Plus with SBA (Prepaid)
♦♦Delta Dental Premier
♦♦Assurant Heritage Secure (Prepaid)
♦♦Delta Dental PPO — Choice
♦♦CIGNA Dental Care Plan (Prepaid)
♦♦HealthChoice Dental
Vision Plans:
♦♦Humana/CompBenefits VisionCare Plan
♦♦UnitedHealthcare Vision
♦♦Primary Vision Care Services (PVCS)
♦♦Vision Service Plan (VSP)
♦♦Superior Vision Plan
HealthChoice Life Insurance Plan
♦♦Now is the time to review your life insurance coverage and your beneficiaries. To change your beneficiaries, complete the Beneficiary Designation Form which is available on the HealthChoice website or contact HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.4
2012 Plan Year
Options for Medicare Members
During Option Period you can:
♦♦Change health and/or dental plans that are already in place
♦♦Drop benefits and/or dependents
♦♦Decrease the amount of life insurance coverage
♦♦Enroll in a vision plan if you have not dropped that coverage within the past 12 months
♦♦Drop or change vision plans
Eligibility Requirements
To participate in the Medicare supplement plans described in this Guide, you must be:
♦♦Entitled to benefits under Medicare Part A and enrolled in Medicare Part B.
♦♦Enrolled in only one Part D plan. If you have Part D coverage through another plan and want to continue that coverage, you must select the HealthChoice High or Low Option Medicare Supplement Plan Without Part D. Enrolling in another Medicare supplement plan with Part D will end your current Part D coverage.
Enrollment in Medicare Part B
All Medicare eligible individuals, except current employees, must be enrolled in a Medicare plan through OSEEGIB. To maximize benefits, you need to be enrolled in Medicare Part B. HealthChoice Medicare plans do not require you to be enrolled in Part B, but pay benefits as if you are. The other Medicare plans offered through OSEEGIB require you to be enrolled in Medicare Part B.
Your Current Coverage
Your current coverage is listed in the upper right-hand corner of your personalized Option Period Enrollment/Change Form. Your form is being mailed in a separate security envelope. If you want to, you can switch to a different plan. If you do not return your enrollment/change form by December 7, you will automatically be enrolled in the same coverage you currently have.
Service Areas
The Medicare supplement plans offered through OSEEGIB provide coverage throughout the United States. If you move out of the United States, you must notify your plan so that you can be disenrolled and find a new plan in your area.5
2012 Plan Year
Creditable Coverage Notice
Prescription drug coverage is called creditable when the plan’s prescription drug coverage pays, on average, at least as much as Medicare’s standard prescription drug coverage. The Medicare supplement plans offered through OSEEGIB provide coverage that is equal to, or better than, the standard benefits of Medicare’s prescription drug plan. All plans meet or exceed the standards and the low option plans meet the standards set by the Centers for Medicare and Medicaid Services.
Medicare Premiums, Deductibles, Coinsurance, and Copays
As of the print date of this Guide, the amounts for Medicare premiums and deductibles for 2012 were not available. Use this Guide together with your 2012 Medicare & You handbook for more information and exact amounts.
Part D Income-Related Premium Adjustment
If you are a member of one of the Medicare supplement plans offered through OSEEGIB, your premium for Part D prescription drug coverage is included in your regular monthly premium. However, if your income is above a certain level, you must pay an additional premium for your Part D coverage. If you have to pay an extra amount, the Social Security Administration will send you a letter telling you what the extra amount will be. For more information, call Social Security at 1-800-772-1213, Monday through Friday, 7 a.m. to 7 p.m., Central time. TTY users call toll-free 1-800-325-0778.
Medicare’s Limiting Charge
Under Medicare guidelines, the highest amount you can be charged for a covered service is called the limiting charge. This applies when you receive services from doctors and other health care service suppliers who don’t accept Medicare assignment. The limiting charge is 15% over Medicare’s approved amount. It applies only to certain services and not to supplies or equipment.
Charges for Services Not Covered by Medicare
Any charges for services or supplies which are not covered by Medicare or covered under your plan are your financial responsibility.
Extra Help Paying for Part D ― Medicare Low-Income Subsidy Information
People with limited incomes may get extra help to pay for prescription drug costs. This extra help is known as the low-income subsidy or LIS. Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual pharmacy deductibles, 6
2012 Plan Year
and prescription copays. Those who qualify are not subject to the Coverage Gap or the late enrollment penalty. To learn more or to apply, call Social Security toll-free at 1-800-772-1213, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time. TTY users call toll-free 1-800-325-0778. More information is also available on their website at www.socialsecurity.gov.
Extra Help ― If You Are Already Qualified
If you already get help paying for your prescription drugs, some of the information in this Guide about premiums and Part D drug costs is not correct for you. The amounts of your monthly premiums and pharmacy costs will be less. Your plan may request a copy of your letter from Social Security confirming you are qualified. Once you enroll in a Part D plan, Medicare or your plan will tell us the amount of assistance you will receive. We will then send you information about the amount you will pay.
Confirming Your Coverage
♦♦Plan changes made during Option Period will be reflected on the Confirmation Statement you receive from OSEEGIB.
♦♦Review your Confirmation Statement to make sure your coverage is correct. Contact OSEEGIB Member Services right away if your Confirmation Statement is incorrect, so corrections can be made as soon as possible.
♦♦If you do not make any changes, you will not receive a Confirmation Statement. Keep your personalized Option Period Enrollment/Change Form as proof of your coverage.
COBRA Coverage
A dependent who becomes ineligible for coverage may be able to continue health, dental, and/or vision coverage under the federal COBRA law. Examples of qualifying events that allow dependents to continue coverage under COBRA include:
♦♦A child reaching age 26
♦♦Divorce of a spouse
♦♦Your death
It is the policy of the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, that one person must always pay the primary member premium. When a spouse, child, or children are insured under a particular benefit, but the member did not keep that coverage, one person is always billed the primary member rate.
Finding a Provider
You can choose any health care provider you want, but selecting a provider who accepts Medicare assignment will lower your out-of-pocket costs. Assignment means your provider has agreed to accept the Medicare approved amount as full payment for covered services.To find a dental or vision provider or to check the network status of a provider, visit each plan’s website or call its customer service number for assistance. See Help Lines on page 41.
Address Information
Medicare requires that you report changes in your home address to your plan.
If You Are Enrolled in a Medicare Supplement Plan With Part D
Your Medicare Part D plan through OSEEGIB provides Part D prescription drug coverage. If you enroll in a Medicare Part D plan outside of OSEEGIB, Medicare must disenroll you from your current Part D plan. If this occurs, OSEEGIB must change your coverage to the HealthChoice Medicare Supplement Plan Without Part D. Your coverage will be similar and include prescription drug coverage, but not Part D benefits. You must continue on the plan without Part D benefits until the next Option Period and pay the higher premium for that plan, or since you have other Part D (or prescription) coverage, you may drop your health and prescription coverage through OSEEGIB, or drop your Part D coverage, whichever you decide. If you drop your coverage through OSEEGIB, you cannot regain coverage through OSEEGIB in the future, and you will lose any premium contribution made by your retirement system.
If You Currently Have Health Coverage Through Your Employer or Union
If you or your spouse have health coverage through an employer or union, joining one of the plans offered by OSEEGIB may change your coverage. Please read the information sent to you by your employer or union. For questions, visit your employer’s/union’s website or see your benefits administrator.
If you leave your plan and do not get other Medicare Part D coverage or other coverage that is as good as Medicare’s (Creditable Coverage), in the future, you may have to pay Medicare’s late enrollment penalty in addition to your premium for Part D prescription drug coverage.
Release of Information
OSEEGIB/HealthChoice uses and discloses your protected health information for your treatment, payment for services, and business operations. OSEEGIB/HealthChoice will also release your information, including your prescription drug event date, to Medicare, who may release it for research and other purposes which follow federal statutes and regulations.
2012 Plan Year
78
2012 Plan Year
More Information
♦♦If you have eligibility questions, call OSEEGIB Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
♦♦Plan specific benefit questions must be directed to each plan. See Help Lines on page 41.
♦♦You can also call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call toll-free 1-877-486-2048.9 2012 Plan Year
Section II
HealthChoice Medicare
Supplement Plans
10
2012 Plan Year
2012 Annual Notice of Change
Please read this HealthChoice Annual Notice of Change. Each year, Medicare prescription drug plans may change premiums, cost-sharing amounts, and benefits. These changes may include increasing premiums, increasing or decreasing cost-sharing amounts, and adding or subtracting benefits. This notice provides a summary of how HealthChoice benefits and costs will change and what you will pay for services beginning January 1, 2012.
Federal Contracting Statement for Medicare Part D
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of State Finance, contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the federal government, to provide Part D coverage. The HealthChoice Employer PDP Medicare Supplement Plans With Part D are Medicare approved Part D plans. OSEEGIB is a Medicare approved Part D sponsor, and its contract with CMS is renewed annually and is not guaranteed beyond the 2012 contract year. OSEEGIB has the right to refuse to renew its contract with CMS or CMS may refuse to renew its contract with OSEEGIB. Termination or non-renewal of the contract will result in the termination of your enrollment in a HealthChoice Medicare Supplement Plan With Part D.
HealthChoice Employer PDP Medicare Supplement Plans With Part D
The Plans with Part D benefits include Medicare Part D prescription drug coverage.
HealthChoice Medicare Supplement Plans Without Part D
The Plans without Part D include pharmacy benefits, but they are not Medicare Part D plans. These plans are specifically designed for members who:
♦♦Already have Medicare Part D coverage through another plan or employer.
♦♦Receive a subsidy for prescription drug benefits from their or their spouse’s employer.
♦♦Receive Veterans Administration health benefits for prescription drugs.
Note: Premiums for the plans without Part D are higher because HealthChoice does not receive a subsidy from Medicare for members enrolled in these plans.
Enrolling in a HealthChoice Employer PDP Medicare Supplement Plan With Part D
If you are enrolling in or changing your coverage to a HealthChoice Employer PDP Medicare Supplement Plan With Part D, you must complete and return the Application for HealthChoice Employer PDP Medicare Supplement With Part D to OSEEGIB along with your Option Period Enrollment/Change Form. This application is available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. First, go to Members and click Medicare Members, then scroll down to Forms and Applications. You can also request an application by contacting HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
Changes to the HealthChoice Medicare Supplement Plans’ Monthly Premiums
The chart below compares 2011 monthly premiums with the new 2012 premiums:
Plan Name
2011
Premium
2012
Premium
Increase
HealthChoice Employer PDP High Option With Part D
$308.34
$332.54
$24.20
HealthChoice Employer PDP Low Option With Part D
$251.66
$273.02
$21.36
HealthChoice High Option Without Part D
$363.06
$383.34
$20.28
HealthChoice Low Option Without Part D
$306.38
$323.82
$17.44
If you currently pay a premium for Medicare Part A, Part B, or Part D, you must continue to pay your premiums in order to keep your Medicare coverage.
Extra Help Paying for Part D ― Medicare Low Income Subsidy Information
If you qualify for the low-income subsidy through Social Security, you pay a reduced monthly premium for the prescription drug portion of your coverage. This extra help also assists you in paying for your prescription drugs. If you qualify in 2012, the chart below shows the amount you will pay for your prescription drugs based on your Rx group. For more information, contact Social Security.
Groups
If you pay up to this much in 2011
You will pay up to this much in 2012
Rx 1
$0 deductible
$0 deductible
$0 copay
$0 copay
Rx 2
$0 deductible
$0 deductible
$1.10 generic and Preferred-brand copay
$1.10 generic and Preferred-brand copay
$3.30 non-Preferred brand and other drug copays
$3.30 non-Preferred brand and other drug copays
Rx 3
$0 deductible
$0 deductible
$2.50 generic and Preferred-brand copay
$2.60 generic and Preferred-brand copay
$6.30 non-Preferred brand and other drug copays
$6.50 non-Preferred brand and other drug copays
Rx 4-7
$63 deductible
$65 deductible
15% copay
15% copay
11
2012 Plan Year2012 Plan Year
12
Health Benefit Changes
The health benefits provided by the HealthChoice Medicare Supplement Plans are designed to provide supplemental benefits to Medicare Part A and Part B. HealthChoice benefits will be adjusted effective January 1, 2012, to coincide with any changes made by Medicare.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from the HealthChoice Medicare Supplement Plans.
♦♦Initial Enrollment Period ― This is the time period when you first become eligible for enrollment in a Medicare Part D plan.
♦♦The Annual Coordinated Election Period – This year, the HealthChoice annual Option Period (Annual Coordinated Election Period) runs through December 7, 2011. All enrollments and plan changes must be completed by December 7. Once the annual Option Period ends, plan changes cannot be made until the next annual Option Period.
♦♦Special Enrollment Periods – Special Enrollment Periods are allowed under certain situations. Coverage is effective following the processing of your paperwork. Examples include:
• You move outside the United States.
• CMS or HealthChoice terminates the Plans’ participation in the Part D program.
• You lose Creditable Coverage for reasons other than failure to pay premiums.
• You meet other exception rules as set out by CMS.
• For more information on Special Enrollment Periods, contact HealthChoice Member Services. See Help Lines on page 41 of this Guide.
ID Cards
HealthChoice members have two ID cards, one for health and/or dental benefits, and another for pharmacy benefits. If you are currently a HealthChoice member, continue using your current ID cards. If you are new to HealthChoice, you will be issued new ID cards.2012 Plan Year
13
Pharmacy Benefit Changes
Tobacco cessation medications will be available for a $0 copay and include:
♦♦Buproban 150mg SA Tablets
♦♦Bupropion HCL SR 150mg Tablets
♦♦Chantix 0.5mg and 1mg Tablets
♦♦Nicotrol 10mg Cartridge
♦♦Nicotrol NS 20mg/in Nasal Spray
Specialty medications copays will increase for each 30-day fill:
♦♦Preferred medication copays will increase from $57.50 to $60.00
♦♦Non-Preferred medication copays will increase from $115 to $120
In accordance with CMS guidelines, the following amounts are changing. See below:
Plan Name
Pharmacy
Deductible
Initial Coverage Limit (Low Option Only)
Annual
Out-of-Pocket Maximum
Charges Applied to Out-of-Pocket Maximum
HealthChoice Employer PDP High Option With Part D
Not
applicable
Not
applicable
Increases
from
$4,550 to $4,700
All out-of-pocket costs for covered drugs purchased at Network Pharmacies count toward the annual out-of-pocket maximum
HealthChoice High Option Without Part D
HealthChoice Employer PDP Low Option With Part D
Increases from $310 to $320
Increases
from
$2,840 to $2,930
HealthChoice Low Option Without Part D
HealthChoice Comprehensive Medicare Formulary (List of Covered Drugs)
Enclosed with this Guide is a copy of the new HealthChoice Comprehensive Medicare Formulary that is effective January 1, 2012. This drug list shows the drugs covered by the Plans. Medicare has reviewed and approved this list of covered drugs. To find out how your medications are covered, please contact Medco toll-free at 1-800-758-3605 or toll-
HealthChoice Pharmacy
Benefit Information2012 Plan Year
14
free TTY 1-800-871-7138, or go to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com.
Be aware there are a number of changes to the formulary. In general, HealthChoice has not changed its drug tiers or copay structure; however, we have added some new drugs to the list and removed others. We have added some drugs that have recently become available, and we have replaced some expensive brand-name drugs with less costly generic alternatives.
HealthChoice has also added some restrictions to certain drugs and reduced the restrictions on others. Some examples of restrictions include the requirement to first get Plan approval before filling a medication, a limit on the quantity of medication you can receive, and the need to try a different drug first to see how well it works for you.
Both brand-name and generic drugs are covered and are sorted into five tiers:
♦♦Tier 1 – Generics
♦♦Tier 2 – Preferred Brand
♦♦Tier 3 – Non-Preferred Brand
♦♦Tier 4 – Very high cost and unique drugs
♦♦Tier 5 – Tobacco cessation medications
The drugs in Tiers 1, 2, and 4 offer the lowest or Preferred copay, Tier 3 drugs have the highest copay, and Tier 5 drugs (tobacco cessation products) have a $0 copay. Drugs not listed in the formulary are not covered.
If HealthChoice makes a formulary change that alters your drug’s tier level or increases its cost, we will notify you 60 days before the change so you can review your options.
When Changes Affect a Drug You Currently Take
If you are currently taking a drug that is not listed in the HealthChoice Comprehensive Medicare Formulary, or coverage for your drug has changed; e.g., it has moved to a higher cost-sharing tier, or it has new restrictions, you have a couple of options:
♦♦In some situations, HealthChoice will cover a one-time, temporary supply of your drug when your current supply runs out. This temporary supply is for a maximum of 30 days.
♦♦You and your doctor can find a covered drug that treats your medical condition.
♦♦Your doctor can ask for an exception/prior authorization for your current medication.
Pharmacy Prior Authorization
Prior authorization medications are medications that may be covered under the plan if the prescribed use meets approved guidelines. Prior authorization requests must be submitted by 15
2012 Plan Year
your physician. Please note, HealthChoice may have added or removed certain medications from the list of drugs that require prior authorization.
Quantities of Medications
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations. Some medications have a maximum quantity limitation and/or the medication is not dispensed in a tablet or capsule form. Be aware that quantity limitations may have been added to or removed from some medications for 2012. Also, be aware that under certain circumstances, HealthChoice will make an exception to quantity limitations.
Transition Supply of Medication (Applies Only to Plans With Part D)
During transition to a HealthChoice Part D plan or transition to a formulary medication, you can be authorized to purchase a one-time supply of a non-covered medication. This transition supply, not to exceed a 34-day supply, is available to help you make a successful transition to a HealthChoice Medicare Formulary medication. This temporary supply will be provided, when necessary, prior to initiating or completing the coverage review process for a medication requiring prior authorization. Please note that under certain circumstances, this 34-day supply may be extended. For information on how to obtain a covered transition supply of medication, have your pharmacy contact Medco. See Help Lines on page 41.
Network Pharmacy Access
The HealthChoice Pharmacy Network includes more than 900 pharmacies across Oklahoma and nearly 60,000 pharmacies nationwide. They are called Network Pharmacies because they contract with our Plans to provide covered prescription drugs to members. In most cases, your prescriptions are covered only if they are filled at a Network Pharmacy. Network Pharmacies provide electronic claims processing, so generally, there are no paper claims to file. Sometimes a pharmacy leaves the Network. When this occurs, you will have to get your prescriptions filled at another Network Pharmacy. To locate a HealthChoice Network Pharmacy near you, go to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. Click Find a Provider in the top menu bar and then select HealthChoice Network Pharmacies. You can also contact Medco, 24 hours a day, 7 days a week, at the following numbers:
♦♦Members with Part D call toll-free 1-800-590-6828
♦♦TDD users call toll-free 1-800-716-3231
♦♦Members without Part D call toll-free 1-800-903-8113
♦♦TDD users call toll-free 1-800-825-12302012 Plan Year
16
Non-Network Pharmacy Benefits
Although HealthChoice may cover your covered prescriptions if they are purchased at a non-Network pharmacy, a reduced, non-Network benefit may apply. An exception may be made in the event of an emergency. It is considered an emergency when you:
♦♦Travel outside your plan’s service area and run out of medication, or become ill and need a covered medication and are unable to access a Network Pharmacy
♦♦Cannot get a covered medication within your Plan’s pharmacy network in timely manner
♦♦Fill a prescription for a covered medication that is not regularly stocked at a Network Pharmacy
♦♦Receive a covered medication that is dispensed by a non-Network outpatient facility, such as an emergency room, clinic, or surgery center
If you must use a non-Network pharmacy, you will have to pay the full cost for your prescription and then ask HealthChoice to repay you for its share of the cost. Before you fill a prescription under these circumstances, when possible, check to see if there is a Network Pharmacy in your area by visiting the HealthChoice website at www.sib.ok.gov or healthchoiceok.com. You can also contact Medco at the following numbers:
♦♦Members with Part D call toll-free 1-800-590-6828
♦♦TDD users call toll-free 1-800-716-3231
♦♦Members without Part D call toll-free 1-800-903-8113
♦♦TDD users call toll-free 1-800-825-123017
Medicare Part A (Hospitalization) Services
All benefits are based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except the Part A deductible
100% of the Part A deductible
0%
61st through 90th day
All except the coinsurance per day
The coinsurance per day
0%
91st day and after while using Medicare’s 60 lifetime reserve days
All except the coinsurance per day
The coinsurance per day
0%
Once Medicare’s lifetime reserve days are used, HealthChoice provides additional lifetime reserve days
Limited to 365 days
0%
100%
of Medicare eligible expenses
Certification by HealthChoice is required
0%
Beyond the 365 HealthChoice lifetime reserve days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year.
First 20 days
All approved amounts
0%
0%
21st through 100th day
All except the coinsurance per day
The coinsurance per day
0%
101st day and after
0%
0%
100%
Summary of HealthChoice High and Low Option
Medicare Supplement Plans
2012 Plan YearServices
or Items
Description
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Medicare Part A (Hospitalization) Services ― Continued
2012 Plan Year
18
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Services
or Items
Description
Medicare Part B Pays
HealthChoice Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
The Part B deductible
0%
0%
The Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges in excess of Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%Medicare Part B (Medical) Services ― Continued
Services
or Items
Description
Medicare Part B Pays
HealthChoice Pays
You
Pay
Home Health Care:
Medicare approved services
Medically necessary skilled care and medical supplies
100%
0%
0%
Durable Medical Equipment
The Part B deductible
0%
0%
100%
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
One-time Initial Wellness Physical Exam:
To be completed within 12 months of the day you first enroll in Medicare Part B
All Medicare beneficiaries
80%
No Part B deductible
20%
No Part B deductible
0%
2012 Plan Year
19
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive
Services
Who is
Covered
Medicare
Pays
HealthChoice Pays
You Pay
Screening Mammogram:
Once every
12 months
All female Medicare beneficiaries age 40 and older
80%
No Part B deductible
20%
No Part B deductible
0%Preventive
Services
Who is
Covered
Medicare
Pays
HealthChoice Pays
You Pay
Screening Blood Tests for Early Detection of Cardiovascular (Heart) Disease
All Medicare beneficiaries
100%
0%
0%
Pap Test and Pelvic Exam:
Once every 24 months; includes a clinical breast exam
Once every 12 months if high risk/abnormal Pap test in preceding 36 months
All female Medicare beneficiaries
Pap Test, 100% No Part B deductible
For all other exams, 80%
No Part B deductible
0%
For all other exams, 20%
No Part B deductible
0%
Diabetes Screening Test
All Medicare beneficiaries at risk for diabetes
100%
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes
80% after the Part B deductible
20% after the Part B deductible
0%
Diabetes Monitoring: Includes coverage for glucose monitors, test strips, and lancets
All Medicare beneficiaries with diabetes – must be requested by your doctor
80% after the Part B deductible
20% after the Part B deductible
0%
Bone Mass Measurements: Once every 24 months for qualified individuals
All Medicare beneficiaries at risk for losing bone mass
80% after the Part B deductible
20% after the Part B deductible
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
20Preventive
Services
Who is
Covered
Medicare
Part B Pays
HealthChoice Pays
You Pay
Glaucoma Screening: Once every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of their practice
Medicare beneficiaries at high risk or a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to once every 12 months
Flexible
Sigmoidoscopy:
Limited to once every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to once every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
There is no minimum age for having a colonoscopy
For the fecal occult blood test, 100%
No Part B deductible
For all other tests, 80% after the Part B deductible
0% for the fecal occult blood test
For all other tests, 20% after the Part B deductible
0%
0%
Note: For a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare Approved Amount
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
21
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare Approved Amount.Preventive
Services
Who is Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Prostate Cancer Screening
Digital Rectal Exam: Once every 12 months
Prostate Specific Antigen Test (PSA): Once every 12 months
All male Medicare beneficiaries age 50 and older
For the digital rectal exam, 80% after the Part B deductible
For the PSA test, 100%
No Part B deductible
For the digital rectal exam, 20% after the Part B deductible
0% for the PSA test
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
22
Preventive Services — Vaccinations
Flu Vaccination:
One per flu season
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Hepatitis B
Vaccination:
Medicare beneficiaries at medium to high risk for Hepatitis B
For members with Part D, the vaccine and administration are covered under the HealthChoice pharmacy benefit.
For members without Part D, the vaccine and administration are covered under the Medicare Part B benefit.
For Services Not Covered by Medicare
Services
Benefits
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for
foreign travel
exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 each calendar year, then 20%
All amounts over the $50,000 lifetime maximum
No Medicare deductible2012 Network Pharmacy Benefits
HealthChoice High Option Medicare Supplement Plans
With and Without Part D
2012 Plan Year
23
THIS CHART SHOWS NETWORK BENEFITS
There is no annual deductible and no Coverage Gap. There is an annual out-of-pocket maximum. Discounts apply after $2,930 in total drug spend.
Prescription
Medications
Medicare
Pays
HealthChoice
Pays
You
Pay
Generic (Tier 1) or Preferred (Tier 2) drugs costing $100 or less
$0
Allowed Charges after your copay
Copay up to $30 maximum
Generic (Tier 1) or Preferred (Tier 2) drugs costing more than $100
$0
Allowed Charges after your copay
Copay of 25% up to $60 maximum
Non-Preferred (Tier 3) drugs costing $100 or less
$0
Allowed Charges after your copay
Copay up to $60 maximum
Non-Preferred (Tier 3) drugs costing more than $100
$0
Allowed Charges after your copay
Copay of 50% up to $120 maximum
Preferred, high cost or specialty (Tier 4) drugs
$0
Allowed Charges after your copay
Copay is based on the quantity of medication
Preferred,(Tier 5) tobacco cessation prescription drugs
$0
Allowed Charges
$0 copay
DISCOUNTS AFTER DRUG SPEND REACHES $2,930
Once total drug spend reaches $2,930, a 50% discount is applied to the copay for brand-name drugs.
THE PHARMACY OUT-OF-POCKET MAXIMUM
Out-of-Pocket Maximum
After Out-of-Pocket is Met
The annual out-of-pocket maximum is $4,700.
Only copays for covered prescription drugs purchased at Network Pharmacies apply to the out-of-pocket maximum. See the chart above for copay amounts.
After your pharmacy out-of-pocket costs reach $4,700, HealthChoice pays 100% of Allowed Charges for covered prescription drugs purchased at Network Pharmacies for the remainder of the calendar year.
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limits.THE CHART BELOW SHOWS NETWORK BENEFITS
Annual
Deductible
$320
Initial
Coverage Limit
$2,610
Coverage
Gap
$3,727.50
Annual Out-of-Pocket Maximum
$4,700
You pay 100% of $320
After the deductible, you and HealthChoice share the costs of the next $2,610 of prescription drug costs.
You pay 25% ($652.50) and
HealthChoice pays 75% ($1,957.50).
You pay 100% of the next $3,727.50 of prescription drug costs.
After you spend $4,700 out-of-pocket, HealthChoice pays 100% of Allowed Charges for covered prescription drugs for the remainder of the calendar year.
REACHING THE ANNUAL OUT-OF-POCKET MAXIMUM OF $4,700
$ 320.00 Deductible
$ 652.50 25% of the Initial Coverage Limit of $2,610
$3,727.50 Coverage Gap – you pay 100% of costs for prescription drugs
$4,700.00 Your total annual out-of-pocket for covered prescription drugs
YOUR COSTS FOR COVERED MEDICATIONS
You Pay
HealthChoice Pays
Annual deductible of $320
$0
$652.50 (25%) of the next $2,610 of prescription drug costs, the Initial Coverage Limit.
$1,957.50 (75%) of the next $2,610.
During the Coverage Gap, you are responsible for the next $3,727.50 of prescription drug costs; however, you receive a 50% discount on the cost of brand-name drugs and a 14% discount on the cost of generic drugs.
HealthChoice pays the 14% discount on the cost of generic drugs during the Coverage Gap.
$0 after you have spent $4,700 out-of-pocket for prescription drugs.
100% of Allowed Charges for covered drugs for the remainder of the calendar year.
2012 Plan Year
24
2012 Network Pharmacy Benefits for
HealthChoice Low Option Medicare Supplement Plans
With and Without Part D
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.25
2012 Plan Year
Section III
UnitedHealthcare
Senior Supplement PlansUnitedHealthcare Senior Supplement High and Low Option Plans
Medicare Part A (Hospitalization) Services
All Benefits are based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part A Pays
UnitedHealthcare Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except the Part A deductible
100% of the
Part A deductible
0%
61st through 90th day
All except the coinsurance per day
The coinsurance per day
0%
91st day and after while using Medicare’s 60 lifetime reserve days
All except the coinsurance per day
The coinsurance per day
0%
Once Medicare’s lifetime reserve days are used, UnitedHealthcare provides additional lifetime reserve days
Limited to 365 days
0%
100% of Medicare eligible expenses
Certification is required
0%
Beyond the 365 UnitedHealthcare lifetime reserve days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year.
First 20 days
All approved amounts
0%
0%
21st through 100th day
All except the coinsurance per day
The coinsurance per day
0%
101st day and after
0%
0%
100%
2012 Plan Year
26Services
or Items
Description
Medicare
Part A Pays
UnitedHealthcare Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Medicare Part A (Hospitalization) Services ― Continued
2012 Plan Year
27
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
The Part B deductible
0%
0%
The Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges in excess of Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%Medicare Part B (Medical) Services ― Continued
Services
or Items
Description
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Home Health Care:
Medicare Approved Services
Medically necessary skilled care and medical supplies
100%
0%
0%
Durable Medical Equipment
Part B deductible
0%
0%
100%
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
One-time Initial Wellness Physical Exam:
To be completed within 12 months of the day you first enroll in Medicare Part B
All Medicare beneficiaries
80%
No Part B deductible
20%
No Part B deductible
0%
2012 Plan Year
28
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive
Services
Who is
Covered
Medicare
Pays
UnitedHealthcare Pays
You Pay
Screening Mammogram:
Once every 12 months
Female Medicare beneficiaries age 40 and older
80%
No Part B deductible
20%
No Part B deductible
0%Preventive
Services
Who is
Covered
Medicare
Pays
UnitedHealthcare Pays
You Pay
Screening Blood Tests for Early Detection of Cardiovascular (Heart) Disease
All Medicare beneficiaries
100%
0%
0%
Pap Test and Pelvic Exam:
Once every 24 months; includes a clinical breast exam
Once every 12 months if high risk/abnormal Pap test in preceding 36 months
Female Medicare beneficiaries
Pap Test, 100% No Part B deductible
For all other exams, 80%
No Part B deductible
0%
For all other
exams, 20%
No Part B deductible
0%
0%
Diabetes Screening Test
All Medicare beneficiaries at risk for diabetes
100%
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes
80% after the Part B deductible
20% after the Part B deductible
0%
Diabetes Monitoring:
Includes coverage for glucose monitors, test strips, and lancets
All Medicare beneficiaries with diabetes – must be requested by your doctor
80% after the Part B deductible
20% after the Part B deductible
0%
Bone Mass Measurements:
Once every 24 months for qualified individuals
Medicare beneficiaries at risk for losing bone mass
80% after the Part B deductible
20% after the Part B deductible
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
29Preventive
Services
Who is
Covered
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Glaucoma Screening: Once every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of his/her practice
Medicare
beneficiaries at high risk or a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to once every 12 months
Flexible
Sigmoidoscopy:
Limited to once every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to once every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
There is no minimum age for having a colonoscopy
For the fecal occult blood test, 100%
No Part B deductible
For all other tests, 80% after the Part B deductible
0% for the fecal occult blood test
For all other tests, 20% after the Part B deductible
0%
0%
Note: For a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare Approved Amount
2012 Plan Year
Medicare Part B (Preventive) Services ― Continued
30
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare Approved Amount.Medicare Part B (Preventive) Services ― Continued
Preventive
Services
Who is
Covered
Medicare
Part B Pays
UnitedHealthcare
Pays
You
Pay
Prostate Cancer Screening
Digital Rectal Exam: Once every 12 months
Prostate Specific Antigen (PSA) Test: Once every 12 months
All male Medicare beneficiaries age 50 and older
For the digital rectal exam, 80% after the Part B deductible
For the PSA test, 100% No Part B deductible
For the digital rectal exam, 20% after the Part B deductible
0% for the PSA test
0%
0%
2012 Plan Year
Preventive Services - Vaccinations
Flu Vaccination:
One per flu season
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Hepatitis B Vaccination:
Medicare beneficiaries at medium to high risk for Hepatitis B
The vaccine and administration are covered under the pharmacy benefit.
Services Not Covered by Medicare
Services
Benefits
Medicare
Part B Pays
UnitedHealthcare Pays
You Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for foreign travel exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 each calendar year, then 20%
Amounts over the $50,000 lifetime maximum
31Prescription
Medications
You
Pay
Tier 1 — Preferred Generics
$10
Tier 2 — Preferred Brand
$30
Tier 3 — Non-Preferred
$60
Tier 4 — Specialty
33%
UnitedHealthcare Senior Supplement High and Low Option Plans — You pay the applicable copays of $10 for Tier 1 prescriptions, $30 for Tier 2 prescriptions, and $60 for Tier 3 prescriptions. For prescriptions in the Specialty Tier, you pay 33% of the discounted network price. You can find a complete formulary listing on www.UnitedhealthRxforGroups.com. If the formulary changes, you will be notified in writing before the change. Only Medicare Part D covered drugs will impact your Medicare prescription drug plan annual out-of-pocket spending.
Certain prescription drugs have maximum quantity limits. Your provider must get prior authorization from UnitedHealthcare for certain prescription drugs.
Once you are out-of-pocket $2,930 (the Initial Coverage Limit) in copays and/or specialty prescriptions, you are responsible for 100% of the discounted network price for all prescriptions except for Tier 1 drugs. After you are out-of-pocket $4,700, you pay 5% or a minimum of $2.60 for generics and a minimum of $6.50 for brand-name prescriptions.
Additionally, a mail order benefit is available. You can receive a 90-day supply of prescriptions for two copays. The coverage, during and after the gap, also applies.
2012 Plan Year
UnitedHealthcare Senior Supplement
High and Low Option Plans
Prescription Drug Coverage
322012 Plan Year
33
Section IV
Dental and Vision
Plan Options2012 Plan Year
34
Comparison of Benefits For Dental Plans
Your Costs for Network Services
HealthChoice
Dental
CIGNA Dental Care
Plan (Prepaid)
Assurant
Freedom
Preferred
ANNUAL
DEDUCTIBLE
Network: $25 Basic and Major services combined
Non-Network: $25 Preventive, Basic, and Major services combined
No deductible or plan maximum
$5 office copay applies
$25 per person, per calendar year, waived for preventive services in-network
PREVENTIVE CARE
Cleanings, routine oral exams
Allowed Charges apply
Network: $0
Non-Network: $0 of Allowed Charges after deductible
Sealant: $15 per tooth
No charge for routine cleaning once every 6 months
No charge for topical fluoride application (through age 18)
No charge for periodic oral evaluations
$0 with no deductible when in-network
BASIC CARE
Extractions, oral surgery
Allowed Charges apply
Network: 15%
Non-Network: 30%
Deductible applies
Amalgam: One surface, permanent teeth $21
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and customary when in-network,
Deductible applies
MAJOR CARE
Dentures, bridge work
Allowed Charges apply
Network: 40%
Non-Network: 50%
Deductible applies
Root canal, anterior: $355
Periodontal/scaling/root planing 1-3 teeth (per quadrant): $71
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and customary when in-network
Deductible applies
All plan changes are indicated by bold text.2012 Plan Year
35
Comparison of Benefits For Dental Plans
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental
PPO — POS
In-Network and Out-of-Network
Delta Dental Premier
In-Network and Out-of-Network
Delta’s Choice
PPO
PPO Network
No deductibles
$25 per person, per year applies to Basic and Major Care only
$50 per person, per year applies to diagnostic, Preventive, Basic, and Major Care
$100 per person, per year applies to Major Care only (Level 4)
No charge for routine cleaning (once every 6 months)
No charge for topical fluoride application (up to age 18)
No charge for periodic oral evaluations
$0 of allowable amounts
No deductible applies
Includes diagnostic
$0 of allowable amounts after deductible
Includes diagnostic
Schedule of covered services and copays. Copay examples:
Routine cleaning $5
Periodic oral evaluation $5
Topical fluoride application (up to age 19) $5
Includes diagnostic
Fillings
Minor oral surgery
Refer to the copayment schedule for each plan
15% of allowable amounts after deductible
30% of allowable amounts after deductible
Schedule of covered services and copays Copay example:
Amalgam - one surface, primary or permanent tooth $12
Root canal
Periodontal
Crowns
Refer to the copayment schedule for each plan
40% of allowable amounts after deductible
50% of allowable amounts after deductible
Schedule of covered services and copays Copay examples:
Crown - porcelain/ceramic substrate $241
Complete denture - maxillary $3202012 Plan Year
36
Comparison of Benefits For Dental Plans
Your Costs for Network Services
HealthChoice
Dental
CIGNA Dental Care Plan (Prepaid)
Assurant
Freedom
Preferred
ORTHODONTIC CARE
Allowed Charges apply
Network: 50%
Non-Network: 50%
12-month waiting period may apply
No lifetime orthodontic maximum for Network or non-Network
Covered for members under age 19 and members age 19 and older with TMD
$2,280 out-of-pocket for children through age 18
$3,120 out-of-pocket for adults
24-month treatment excludes orthodontic treatment plan and banding
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime maximum for members under age 19
12-month waiting period may apply
PLAN YEAR MAXIMUM
Network and non-Network $2,000 per person, per year
No maximum
$2,000
FILING CLAIMS
Network: No claims to file
Non-Network: You file claims
No claims to file
Member/provider must file claims
All plan changes are indicated by bold text.2012 Plan Year
37
Comparison of Benefits For Dental Plans
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental
PPO — POS
In-Network and Out-of-Network
Delta Dental Premier
In-Network and Out-of-Network
Delta’s Choice
PPO
PPO Network
25% discount
Orthodontic benefits are available to eligible adults and dependent children
40% of allowable amounts, up to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
40% of allowable amounts, up to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
You pay amounts in excess of $50 per month
Lifetime maximum up to $1,800
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
No annual maximum for general dentist
$2,500 per person, per year
$3,000 per person, per year
$2,000 per person, per year
No claims to file
Claims are filed by participating dentists
Claims are filed by participating dentists
Claims are filed by participating dentists2012 Plan Year
Comparison of Benefits for Vision Plans
38
Humana/CompBenefits
VisionCare Plan
Primary Vision
Care Services, Inc.
Covered Services
In-Network
Out-of-
Network
In-Network
Out-of-
Network
Eye
Exams
$10 copay
One per year
No copay; Plan pays up to $35; One per year
$0 copay
No limit on exams
Plan pays up to $40; One per year
Lenses
Each Pair
$25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%)
A discount applies to progressive lenses
One pair per year
Plan pays up to:
$25 single
$40 bifocals
$60 trifocals
$100 lenticular
One per year
You pay wholesale cost with no limit on number of pairs
You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames One per year
Frames
$25 material copay applies to lenses and/or frames;
$45 wholesale frame allowance;
One pair per year
$25 copay
Plan pays up to $45
One pair per year
You pay wholesale cost with no limit on number of pairs
You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
One per year
Contact Lenses
$130 allowance for conventional or disposable lenses and fitting fee in lieu of all other benefits
Medically necessary, Plan pays 100%
One set per year
$130 allowance for exam, contacts, and fitting fee in lieu of all other benefits
Medically necessary
Plan pays $210
One set per year
You pay wholesale cost for contacts
$50 fee applies to all soft contact lens fittings; $75 to rigid or gas permeable lens fittings; $150 to hybrid contact lens fittings Replacement lenses do not have these fees
Limit of one set annually in lieu of eyeglasses You pay normal doctor’s fees, reimbursed up to $60
Laser
Vision Correction
$895 copay conventional
$1,295 copay custom
$1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
No benefit
Discount nationwide at The Laser Center (TLC)
No benefit
All plan changes are indicated by bold text.2012 Plan Year
Comparison of Benefits for Vision Plans
39
Superior Vision Plan
UnitedHealthcare Vision
Vision Service Plan (VSP)
In-Network
Out-of-
Network
In-Network
Out-of-
Network
In-Network
Out-of-
Network
$10 copay
One per year
OD-$26 max
MD-$34 max
$10 copay
One per year
Plan pays up to $40
$10 copay
One per year
$10 copay; Plan pays up to $35
$25 copay
One pair per year
Plan pays up to:
$26 single
$39 bifocals
$49 trifocals
$78 lenticular
$25 copay
One pair per year
Lens options covered in full include:
• UV coating
• Tints
Plan pays up to:
$40 single
$60 bifocals
$80 trifocals
$80 lenticular
$25 annual material copay
One set per year
Polycarbonate lenses covered in full for dependent children
35-40% savings on non-covered lens options
$25 annual material copay
Plan pays up to:
$25 single
$40 bifocals
$55 trifocals
$80 lenticular
$25 copay
Plan pays up to $125
One pair per year
Plan pays up to $68
$25 copay
$130 allowance
One pair per year
Plan pays up to $45
$25 annual material copay
$120 allowance
20% off any out-of-pocket costs above the allowance
One pair per year
$25 annual material copay
Plan pays up to $45
$25 standard fitting copay
After copay, Plan pays 100%
$25 specialty fitting copay
After copay, Plan pays up to $50 Plan pays up to $120 for elective contacts
Medically necessary contacts are covered in full (in lieu of glasses)
Fitting fee is not a covered benefit
$0 copay
Plan pays up to $100
For medically necessary contacts, Plan pays up to $210
(in lieu of glasses)
$25 copay covers fitting/evaluation fees, contacts (including disposables), and up to 2 follow-up visits
(in lieu of glasses)
Plan pays up to $150
For medically necessary contacts, Plan pays up to $210
(in lieu of glasses)
$0 copay
$120 allowance applies to the cost of contact lens exam and contact lenses
15% discount on contact lens exam (in lieu of glasses)
Contact lens exam covered in full after a copay of up to $60
$0 copay
Plan pays up to $105 for disposable or conventional contact lenses
(in lieu of glasses)
20 to 50% savings on LASIK surgery
No benefit
Access to
discounted refractive eye surgery from provider locations in the U.S.
No benefit
Laser vision correction services at a reduced cost through VSP’s contracted laser surgery centers
No benefitNotes
2012 Plan Year
4041
2012 Plan Year
Dental Plans’ Help Lines
Assurant, Inc. Dental
Prepaid Plan, toll-free
1-800-443-2995
Indemnity Plan, toll-free
1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Dental Care Plan (Prepaid)
Toll-free
1-800-244-6224
Toll-free Relay Service
1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area
1-405-607-2100
Toll-free
1-800-522-0188
Website: www.deltadentalok.org
Vision Plans’ Help Lines
Humana/CompBenefits VisionCare Plan
Toll-free
1-800-865-3676
Toll-free TDD
1-877-553-4327
Website
www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
Toll-free
1-888-357-6912
Toll-free TDD
1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
Toll-free
1-800-507-3800
Toll-free TDD
1-916-852-2382
Website www.superiorvision.com
UnitedHealthcare Vision
Toll-free
1-800-638-3120
Toll-free TDD
1-800-524-3157
Website www.myuhcvision.com
Vision Service Plan (VSP)
Toll-free
1-800-877-7195
Toll-free TDD
1-800-428-4833
Website www.vsp.com
Health Plans’ Help Lines
HealthChoice
Health, Dental, and Life Claims, ID Cards, Benefits and Verification of Coverage
Oklahoma City Area
1-405-416-1800
Toll-free
1-800-782-5218
TDD Oklahoma City
1-405-416-1525
Toll-free TDD
1-800-941-2160
Website www.sib.ok.gov or
www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
Plans With Part D:
Toll-free
1-800-590-6828
Toll-free TDD
1-800-716-3231
Plans Without Part D:
Toll-free
1-800-903-8113
Toll-free TDD
1-800-825-1230
Certification
Toll-free
1-800-848-8121
Toll-free TDD
1-877-267-6367
Member Services and Provider Directory
Oklahoma City Area
1-405-717-8780
Toll-free
1-800-752-9475
TDD Oklahoma City
1-405-949-2281
Toll-free TDD
1-866-447-0436
UnitedHealthcare
Senior Supplement Plans
Toll-free
1-800-851-3802
Toll-free TYY 1-800-851-3802, ext 711
Website www.UHCRetiree.com
If a plan does not list aTDD or TTY number, members should use a relay service to contact the plan.

MDIS #2545
Summary of Benefits
January 1 through December 31, 2012
Medicare
Supplement Plans
Dental Plans
Vision Plans
Life Insurance Plan
State Flower, Indian Blanket
State Animal, Buffalo
Option Period Guide
Plan Year 2012
State Bird, Scissored-tailed Flycatcher
E7848_G1000You should have already received a schedule of retiree Option Period meetings. If you plan to attend one of these meetings, please bring this Guide with you.
Enrollment Information
♦ Your Option Period Enrollment/Change Form is being mailed in a separate security envelope. When you receive your form, review your personalized information in the upper right-hand corner. This section lists the coverage you will have January 1, through December 31, 2012, if you do not make changes to your coverage this Option Period.
If you DO NOT WANT to make changes:
♦ No further action is necessary. You do NOT need to return your Option Period Enrollment/Change Form. OSEEGIB will automatically carry your 2011 coverage over to 2012.
♦ You will not receive a Confirmation Statement from OSEEGIB. Keep your Option Period Enrollment/Change Form as proof of your insurance coverage.
♦ If you live in a long-term care facility, such as a skilled nurse facility or nursing home, do not allow your facility to enroll you in another Medicare Part D plan. Enrollment in another Part D plan will end your Part D coverage through OSEEGIB and cause your premiums to increase.
If you WANT TO make changes, your enrollment form is due by December 7.
♦ The following resources are also available to help you decide on your coverage:
• This Guide • Online Provider Directories • Plan Formularies
• Plan Websites • Customer Service Representatives
♦ Review the premium rates and plan changes for 2012.
♦ Enroll in only one Part D plan.
♦ Check the appropriate boxes on your Option Period Enrollment/Change Form to make changes.
♦♦If you decide to change Part D plans, you must complete and return a separate enrollment application to the plan you select, as well as return your Option Period Enrollment/Change Form to OSEEGIB. Contact each plan to request an application. See Help Lines on page 41.
♦♦If you already have Part D coverage through another employer or union plan, you must select one of the HealthChoice Medicare Supplement Plans Without Part D.
♦ Return your enrollment/change form by December 7.
♦ Review your Confirmation Statement when you receive it to verify your coverage is correct.
♦ If your coverage is listed incorrectly, please contact OSEEGIB Member Services as soon as possible. See Help Lines on page 41.
If you have questions or need more information, please contact OSEEGIB at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D
$332.54 per enrollee
HealthChoice Employer PDP Low Option With Part D
$273.02 per enrollee
HealthChoice High Option Without Part D
$383.34 per enrollee
HealthChoice Low Option Without Part D
$323.82 per enrollee
UnitedHealthcare Senior Supplement High Option
$398.76 per enrollee
UnitedHealthcare Senior Supplement Low Option
$357.63 per enrollee
DENTAL PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
HealthChoice Dental
$30.20
$30.20
$25.18
$65.32
Assurant Freedom Preferred
$28.83
$28.67
$21.50
$57.80
Assurant Heritage Plus (Prepaid)
$11.74
$ 8.86
$ 7.60
$15.20
Assurant Heritage Secure (Prepaid)
$ 7.20
$ 5.98
$ 5.20
$10.38
CIGNA Dental Care Plan (Prepaid)
$ 9.26
$ 6.06
$ 7.08
$15.32
Delta Dental PPO
$33.64
$33.62
$29.26
$74.04
Delta Dental Premier
$38.36
$38.36
$33.38
$84.46
Delta Dental PPO — Choice
$15.06
$34.18
$34.44
$83.60
VISION PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
Humana/CompBenefits VisionCare Plan
$6.76
$5.06
$3.57
$ 4.46
Primary Vision Care Services (PVCS)
$9.25
$8.00
$8.50
$10.75
Superior Vision Plan
$7.14
$7.10
$6.72
$13.80
UnitedHealthcare Vision
$8.18
$5.79
$4.59
$ 6.98
Vision Service Plan (VSP)
$8.76
$5.87
$5.62
$12.64
LIFE PLAN
From $5,000 to $40,000 $1.88 Per $1,000 Unit
Age Rated Life – Cost Per $1,000 from $41,000 and Up
< 30 ---------- $0.03
45 - 49 ------- $0.10
65 - 69 ------- $0.51
30 - 34 ------- $0.03
50 - 54 ------- $0.17
70 - 74 ------- $0.87
35 - 39 ------- $0.04
55 - 59 ------- $0.27
75+ ----------- $1.35
40 - 44 ------- $0.06
60 - 64 ------- $0.31
DEPENDENT LIFE
$0.94 Per $500 Unit, Per Dependent
Monthly Premiums for Medicare Eligible Members
Plan Year January 1, 2012 - December 31, 2012
These rates do not reflect any contribution from your retirement system.MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D
$332.54 per enrollee
HealthChoice Employer PDP Low Option With Part D
$273.02 per enrollee
HealthChoice High Option Without Part D
$391.01 per enrollee
HealthChoice Low Option Without Part D
$330.30 per enrollee
UnitedHealthcare Senior Supplement High Option
$398.76 per enrollee
UnitedHealthcare Senior Supplement Low Option
$357.63 per enrollee
DENTAL PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
HealthChoice Dental
$30.80
$30.80
$25.68
$66.63
Assurant Freedom Preferred
$29.41
$29.24
$21.93
$58.96
Assurant Heritage Plus with SBA (Prepaid)
$11.97
$ 9.04
$ 7.75
$15.50
Assurant Heritage Secure (Prepaid)
$ 7.34
$ 6.10
$ 5.30
$10.59
CIGNA Dental Care Plan (Prepaid)
$ 9.45
$ 6.18
$ 7.22
$15.63
Delta Dental PPO
$34.31
$34.29
$29.85
$75.52
Delta Dental Premier
$39.13
$39.13
$34.05
$86.15
Delta Dental PPO — Choice
$15.36
$34.86
$35.13
$85.27
VISION PLANS
MEMBER
SPOUSE
CHILD
CHILDREN
Humana/CompBenefits VisionCare Plan
$6.90
$5.16
$3.64
$ 4.55
Primary Vision Care Services (PVCS)
$9.44
$8.16
$8.67
$10.97
Superior Vision Plan
$7.28
$7.24
$6.85
$14.08
UnitedHealthcare Vision
$8.34
$5.91
$4.68
$ 7.12
Vision Service Plan (VSP)
$8.94
$5.99
$5.73
$12.89
Monthly COBRA Premiums for Medicare Eligible Members
Plan Year January 1, 2012 - December 31, 2012
Agency policy states that one person must always pay the primary member premium. When a dependent spouse, child, or children are insured under a particular benefit, but the primary member did not keep that benefit, one person is always billed the primary member rate.
Monthly Life Insurance Premiums for Surviving Dependents
Surviving dependents
of current employees
LOW OPTION
$2.60
STANDARD OPTION
$4.32
PREMIER OPTION
$8.64
Spouse
$6,000 of coverage
$10,000 of coverage
$20,000 of coverage
Child (age 6 months to 26)
$3,000 of coverage
$ 5,000 of coverage
$10,000 of coverage
Child (live birth to 6 months)
$1,000 of coverage
$ 1,000 of coverage
$ 1,000 of coverage
Surviving dependents
of former employees
$0.94 Per $500 Unit, Per DependentSection I
Plan Identification Information and General Information................................. 1
Section II
HealthChoice Medicare Supplement Plans....................................................... 9
2012 Annual Notice of Change......................................................................... 10
Section III
UnitedHealthcare Senior Supplement Plans.................................................... 25
Section IV
Dental and Vision Plan Options....................................................................... 33
Help Lines............................................................................................................ 41
TABLE OF CONTENTS
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S. Section 1301, et seq; 17,000 copies have been printed at a cost of $0.61. each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
A text version of this Option Period Guide is available on the OSEEGIB website at www.sib.ok.gov or www.healthchoiceok.com. This Guide is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH at 1-405-521-3514 or toll-free 1-800-523-0288. TDD users call 1-405-521-4672. The information contained in this Guide is only a brief summary of the listed options. All benefits and limitations of these plans are governed in all cases by the relevant plan documents, insurance contracts, handbooks, agency Rules, and the regulations governing the Medicare Prescription Drug Benefit, Improvement, and Modernization Act. The Federal Regulation at 42 C.F.R. § 423 et seq. and the Rules of the Oklahoma Administrative Code, Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations, or exclusions of any plan.Section I
Plan Identification
and
General Information
1
2012 Plan YearPlan Identification Information
Plan Administrator
OSEEGIB
3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Medicare Supplement Plans
Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8780 or toll-free 1-800-752-9475; Fax: 1-405-717-8942
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Website: www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Health, Dental, and Life Claims Administrator
HP Administrative Services, LLC, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
PO Box 24870, Oklahoma City, OK 73124-0870
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
HealthChoice Pharmacy Benefits Manager
Medco, 24 hours a day, 7 days a week
With Part D Plans: Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D Plans: Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Website: www.medco.com
HealthChoice Certification Administrator
APS Healthcare, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
PO Box 700005, Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121 or toll-free TDD 1-877-267-6367
UnitedHealthcare Senior Supplement Plans
Customer Service, Monday through Friday, 9:00 a.m. to 9:00 p.m., Central time
PO Box 6072, Cypress, CA 90630
Toll-free 1-800-851-3802 or toll-free TYY 1-800-851-3802, ext. 711
Website: www.UHCRetiree.com
Medicare
Customer Service, 24 hours a day, 7 days a week
Toll-free 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048
Website: www.medicare.gov
Website Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: www.socialsecurity.gov
2012 Plan Year
23
2012 Plan Year
General Information
The benefit information provided in this Option Period Guide (Summary of Benefits) is only a brief description of each plan’s benefits. If you need additional information to help you make a coverage decision, contact each individual plan. See Help Lines on page 41.
New! New! The Annual Option Period Ends December 7, 2011 New! New!
Medicare has changed the dates for the Annual Coordinated Election Period! This year, you have from October 15 until December 7 to make changes to your coverage. Changes received after the December 7 deadline cannot be accepted.
2012 Plan Changes
There are changes to the plans and plan benefits being offered for 2012.
♦♦Most plan changes are indicated by bold text in each plan’s benefit chart
Plans Participating in 2012
Medicare Supplement Plans:
♦♦HealthChoice Employer PDP High and Low Option Medicare Supplement Plans With Part D
♦♦HealthChoice High and Low Option Medicare Supplement Plans Without Part D
♦♦UnitedHealthcare Senior Supplement High and Low Option Plans
Dental Plans:
♦♦Assurant Freedom Preferred
♦♦Delta Dental PPO
♦♦Assurant Heritage Plus with SBA (Prepaid)
♦♦Delta Dental Premier
♦♦Assurant Heritage Secure (Prepaid)
♦♦Delta Dental PPO — Choice
♦♦CIGNA Dental Care Plan (Prepaid)
♦♦HealthChoice Dental
Vision Plans:
♦♦Humana/CompBenefits VisionCare Plan
♦♦UnitedHealthcare Vision
♦♦Primary Vision Care Services (PVCS)
♦♦Vision Service Plan (VSP)
♦♦Superior Vision Plan
HealthChoice Life Insurance Plan
♦♦Now is the time to review your life insurance coverage and your beneficiaries. To change your beneficiaries, complete the Beneficiary Designation Form which is available on the HealthChoice website or contact HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.4
2012 Plan Year
Options for Medicare Members
During Option Period you can:
♦♦Change health and/or dental plans that are already in place
♦♦Drop benefits and/or dependents
♦♦Decrease the amount of life insurance coverage
♦♦Enroll in a vision plan if you have not dropped that coverage within the past 12 months
♦♦Drop or change vision plans
Eligibility Requirements
To participate in the Medicare supplement plans described in this Guide, you must be:
♦♦Entitled to benefits under Medicare Part A and enrolled in Medicare Part B.
♦♦Enrolled in only one Part D plan. If you have Part D coverage through another plan and want to continue that coverage, you must select the HealthChoice High or Low Option Medicare Supplement Plan Without Part D. Enrolling in another Medicare supplement plan with Part D will end your current Part D coverage.
Enrollment in Medicare Part B
All Medicare eligible individuals, except current employees, must be enrolled in a Medicare plan through OSEEGIB. To maximize benefits, you need to be enrolled in Medicare Part B. HealthChoice Medicare plans do not require you to be enrolled in Part B, but pay benefits as if you are. The other Medicare plans offered through OSEEGIB require you to be enrolled in Medicare Part B.
Your Current Coverage
Your current coverage is listed in the upper right-hand corner of your personalized Option Period Enrollment/Change Form. Your form is being mailed in a separate security envelope. If you want to, you can switch to a different plan. If you do not return your enrollment/change form by December 7, you will automatically be enrolled in the same coverage you currently have.
Service Areas
The Medicare supplement plans offered through OSEEGIB provide coverage throughout the United States. If you move out of the United States, you must notify your plan so that you can be disenrolled and find a new plan in your area.5
2012 Plan Year
Creditable Coverage Notice
Prescription drug coverage is called creditable when the plan’s prescription drug coverage pays, on average, at least as much as Medicare’s standard prescription drug coverage. The Medicare supplement plans offered through OSEEGIB provide coverage that is equal to, or better than, the standard benefits of Medicare’s prescription drug plan. All plans meet or exceed the standards and the low option plans meet the standards set by the Centers for Medicare and Medicaid Services.
Medicare Premiums, Deductibles, Coinsurance, and Copays
As of the print date of this Guide, the amounts for Medicare premiums and deductibles for 2012 were not available. Use this Guide together with your 2012 Medicare & You handbook for more information and exact amounts.
Part D Income-Related Premium Adjustment
If you are a member of one of the Medicare supplement plans offered through OSEEGIB, your premium for Part D prescription drug coverage is included in your regular monthly premium. However, if your income is above a certain level, you must pay an additional premium for your Part D coverage. If you have to pay an extra amount, the Social Security Administration will send you a letter telling you what the extra amount will be. For more information, call Social Security at 1-800-772-1213, Monday through Friday, 7 a.m. to 7 p.m., Central time. TTY users call toll-free 1-800-325-0778.
Medicare’s Limiting Charge
Under Medicare guidelines, the highest amount you can be charged for a covered service is called the limiting charge. This applies when you receive services from doctors and other health care service suppliers who don’t accept Medicare assignment. The limiting charge is 15% over Medicare’s approved amount. It applies only to certain services and not to supplies or equipment.
Charges for Services Not Covered by Medicare
Any charges for services or supplies which are not covered by Medicare or covered under your plan are your financial responsibility.
Extra Help Paying for Part D ― Medicare Low-Income Subsidy Information
People with limited incomes may get extra help to pay for prescription drug costs. This extra help is known as the low-income subsidy or LIS. Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual pharmacy deductibles, 6
2012 Plan Year
and prescription copays. Those who qualify are not subject to the Coverage Gap or the late enrollment penalty. To learn more or to apply, call Social Security toll-free at 1-800-772-1213, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time. TTY users call toll-free 1-800-325-0778. More information is also available on their website at www.socialsecurity.gov.
Extra Help ― If You Are Already Qualified
If you already get help paying for your prescription drugs, some of the information in this Guide about premiums and Part D drug costs is not correct for you. The amounts of your monthly premiums and pharmacy costs will be less. Your plan may request a copy of your letter from Social Security confirming you are qualified. Once you enroll in a Part D plan, Medicare or your plan will tell us the amount of assistance you will receive. We will then send you information about the amount you will pay.
Confirming Your Coverage
♦♦Plan changes made during Option Period will be reflected on the Confirmation Statement you receive from OSEEGIB.
♦♦Review your Confirmation Statement to make sure your coverage is correct. Contact OSEEGIB Member Services right away if your Confirmation Statement is incorrect, so corrections can be made as soon as possible.
♦♦If you do not make any changes, you will not receive a Confirmation Statement. Keep your personalized Option Period Enrollment/Change Form as proof of your coverage.
COBRA Coverage
A dependent who becomes ineligible for coverage may be able to continue health, dental, and/or vision coverage under the federal COBRA law. Examples of qualifying events that allow dependents to continue coverage under COBRA include:
♦♦A child reaching age 26
♦♦Divorce of a spouse
♦♦Your death
It is the policy of the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, that one person must always pay the primary member premium. When a spouse, child, or children are insured under a particular benefit, but the member did not keep that coverage, one person is always billed the primary member rate.
Finding a Provider
You can choose any health care provider you want, but selecting a provider who accepts Medicare assignment will lower your out-of-pocket costs. Assignment means your provider has agreed to accept the Medicare approved amount as full payment for covered services.To find a dental or vision provider or to check the network status of a provider, visit each plan’s website or call its customer service number for assistance. See Help Lines on page 41.
Address Information
Medicare requires that you report changes in your home address to your plan.
If You Are Enrolled in a Medicare Supplement Plan With Part D
Your Medicare Part D plan through OSEEGIB provides Part D prescription drug coverage. If you enroll in a Medicare Part D plan outside of OSEEGIB, Medicare must disenroll you from your current Part D plan. If this occurs, OSEEGIB must change your coverage to the HealthChoice Medicare Supplement Plan Without Part D. Your coverage will be similar and include prescription drug coverage, but not Part D benefits. You must continue on the plan without Part D benefits until the next Option Period and pay the higher premium for that plan, or since you have other Part D (or prescription) coverage, you may drop your health and prescription coverage through OSEEGIB, or drop your Part D coverage, whichever you decide. If you drop your coverage through OSEEGIB, you cannot regain coverage through OSEEGIB in the future, and you will lose any premium contribution made by your retirement system.
If You Currently Have Health Coverage Through Your Employer or Union
If you or your spouse have health coverage through an employer or union, joining one of the plans offered by OSEEGIB may change your coverage. Please read the information sent to you by your employer or union. For questions, visit your employer’s/union’s website or see your benefits administrator.
If you leave your plan and do not get other Medicare Part D coverage or other coverage that is as good as Medicare’s (Creditable Coverage), in the future, you may have to pay Medicare’s late enrollment penalty in addition to your premium for Part D prescription drug coverage.
Release of Information
OSEEGIB/HealthChoice uses and discloses your protected health information for your treatment, payment for services, and business operations. OSEEGIB/HealthChoice will also release your information, including your prescription drug event date, to Medicare, who may release it for research and other purposes which follow federal statutes and regulations.
2012 Plan Year
78
2012 Plan Year
More Information
♦♦If you have eligibility questions, call OSEEGIB Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
♦♦Plan specific benefit questions must be directed to each plan. See Help Lines on page 41.
♦♦You can also call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users call toll-free 1-877-486-2048.9 2012 Plan Year
Section II
HealthChoice Medicare
Supplement Plans
10
2012 Plan Year
2012 Annual Notice of Change
Please read this HealthChoice Annual Notice of Change. Each year, Medicare prescription drug plans may change premiums, cost-sharing amounts, and benefits. These changes may include increasing premiums, increasing or decreasing cost-sharing amounts, and adding or subtracting benefits. This notice provides a summary of how HealthChoice benefits and costs will change and what you will pay for services beginning January 1, 2012.
Federal Contracting Statement for Medicare Part D
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of State Finance, contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the federal government, to provide Part D coverage. The HealthChoice Employer PDP Medicare Supplement Plans With Part D are Medicare approved Part D plans. OSEEGIB is a Medicare approved Part D sponsor, and its contract with CMS is renewed annually and is not guaranteed beyond the 2012 contract year. OSEEGIB has the right to refuse to renew its contract with CMS or CMS may refuse to renew its contract with OSEEGIB. Termination or non-renewal of the contract will result in the termination of your enrollment in a HealthChoice Medicare Supplement Plan With Part D.
HealthChoice Employer PDP Medicare Supplement Plans With Part D
The Plans with Part D benefits include Medicare Part D prescription drug coverage.
HealthChoice Medicare Supplement Plans Without Part D
The Plans without Part D include pharmacy benefits, but they are not Medicare Part D plans. These plans are specifically designed for members who:
♦♦Already have Medicare Part D coverage through another plan or employer.
♦♦Receive a subsidy for prescription drug benefits from their or their spouse’s employer.
♦♦Receive Veterans Administration health benefits for prescription drugs.
Note: Premiums for the plans without Part D are higher because HealthChoice does not receive a subsidy from Medicare for members enrolled in these plans.
Enrolling in a HealthChoice Employer PDP Medicare Supplement Plan With Part D
If you are enrolling in or changing your coverage to a HealthChoice Employer PDP Medicare Supplement Plan With Part D, you must complete and return the Application for HealthChoice Employer PDP Medicare Supplement With Part D to OSEEGIB along with your Option Period Enrollment/Change Form. This application is available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. First, go to Members and click Medicare Members, then scroll down to Forms and Applications. You can also request an application by contacting HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
Changes to the HealthChoice Medicare Supplement Plans’ Monthly Premiums
The chart below compares 2011 monthly premiums with the new 2012 premiums:
Plan Name
2011
Premium
2012
Premium
Increase
HealthChoice Employer PDP High Option With Part D
$308.34
$332.54
$24.20
HealthChoice Employer PDP Low Option With Part D
$251.66
$273.02
$21.36
HealthChoice High Option Without Part D
$363.06
$383.34
$20.28
HealthChoice Low Option Without Part D
$306.38
$323.82
$17.44
If you currently pay a premium for Medicare Part A, Part B, or Part D, you must continue to pay your premiums in order to keep your Medicare coverage.
Extra Help Paying for Part D ― Medicare Low Income Subsidy Information
If you qualify for the low-income subsidy through Social Security, you pay a reduced monthly premium for the prescription drug portion of your coverage. This extra help also assists you in paying for your prescription drugs. If you qualify in 2012, the chart below shows the amount you will pay for your prescription drugs based on your Rx group. For more information, contact Social Security.
Groups
If you pay up to this much in 2011
You will pay up to this much in 2012
Rx 1
$0 deductible
$0 deductible
$0 copay
$0 copay
Rx 2
$0 deductible
$0 deductible
$1.10 generic and Preferred-brand copay
$1.10 generic and Preferred-brand copay
$3.30 non-Preferred brand and other drug copays
$3.30 non-Preferred brand and other drug copays
Rx 3
$0 deductible
$0 deductible
$2.50 generic and Preferred-brand copay
$2.60 generic and Preferred-brand copay
$6.30 non-Preferred brand and other drug copays
$6.50 non-Preferred brand and other drug copays
Rx 4-7
$63 deductible
$65 deductible
15% copay
15% copay
11
2012 Plan Year2012 Plan Year
12
Health Benefit Changes
The health benefits provided by the HealthChoice Medicare Supplement Plans are designed to provide supplemental benefits to Medicare Part A and Part B. HealthChoice benefits will be adjusted effective January 1, 2012, to coincide with any changes made by Medicare.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from the HealthChoice Medicare Supplement Plans.
♦♦Initial Enrollment Period ― This is the time period when you first become eligible for enrollment in a Medicare Part D plan.
♦♦The Annual Coordinated Election Period – This year, the HealthChoice annual Option Period (Annual Coordinated Election Period) runs through December 7, 2011. All enrollments and plan changes must be completed by December 7. Once the annual Option Period ends, plan changes cannot be made until the next annual Option Period.
♦♦Special Enrollment Periods – Special Enrollment Periods are allowed under certain situations. Coverage is effective following the processing of your paperwork. Examples include:
• You move outside the United States.
• CMS or HealthChoice terminates the Plans’ participation in the Part D program.
• You lose Creditable Coverage for reasons other than failure to pay premiums.
• You meet other exception rules as set out by CMS.
• For more information on Special Enrollment Periods, contact HealthChoice Member Services. See Help Lines on page 41 of this Guide.
ID Cards
HealthChoice members have two ID cards, one for health and/or dental benefits, and another for pharmacy benefits. If you are currently a HealthChoice member, continue using your current ID cards. If you are new to HealthChoice, you will be issued new ID cards.2012 Plan Year
13
Pharmacy Benefit Changes
Tobacco cessation medications will be available for a $0 copay and include:
♦♦Buproban 150mg SA Tablets
♦♦Bupropion HCL SR 150mg Tablets
♦♦Chantix 0.5mg and 1mg Tablets
♦♦Nicotrol 10mg Cartridge
♦♦Nicotrol NS 20mg/in Nasal Spray
Specialty medications copays will increase for each 30-day fill:
♦♦Preferred medication copays will increase from $57.50 to $60.00
♦♦Non-Preferred medication copays will increase from $115 to $120
In accordance with CMS guidelines, the following amounts are changing. See below:
Plan Name
Pharmacy
Deductible
Initial Coverage Limit (Low Option Only)
Annual
Out-of-Pocket Maximum
Charges Applied to Out-of-Pocket Maximum
HealthChoice Employer PDP High Option With Part D
Not
applicable
Not
applicable
Increases
from
$4,550 to $4,700
All out-of-pocket costs for covered drugs purchased at Network Pharmacies count toward the annual out-of-pocket maximum
HealthChoice High Option Without Part D
HealthChoice Employer PDP Low Option With Part D
Increases from $310 to $320
Increases
from
$2,840 to $2,930
HealthChoice Low Option Without Part D
HealthChoice Comprehensive Medicare Formulary (List of Covered Drugs)
Enclosed with this Guide is a copy of the new HealthChoice Comprehensive Medicare Formulary that is effective January 1, 2012. This drug list shows the drugs covered by the Plans. Medicare has reviewed and approved this list of covered drugs. To find out how your medications are covered, please contact Medco toll-free at 1-800-758-3605 or toll-
HealthChoice Pharmacy
Benefit Information2012 Plan Year
14
free TTY 1-800-871-7138, or go to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com.
Be aware there are a number of changes to the formulary. In general, HealthChoice has not changed its drug tiers or copay structure; however, we have added some new drugs to the list and removed others. We have added some drugs that have recently become available, and we have replaced some expensive brand-name drugs with less costly generic alternatives.
HealthChoice has also added some restrictions to certain drugs and reduced the restrictions on others. Some examples of restrictions include the requirement to first get Plan approval before filling a medication, a limit on the quantity of medication you can receive, and the need to try a different drug first to see how well it works for you.
Both brand-name and generic drugs are covered and are sorted into five tiers:
♦♦Tier 1 – Generics
♦♦Tier 2 – Preferred Brand
♦♦Tier 3 – Non-Preferred Brand
♦♦Tier 4 – Very high cost and unique drugs
♦♦Tier 5 – Tobacco cessation medications
The drugs in Tiers 1, 2, and 4 offer the lowest or Preferred copay, Tier 3 drugs have the highest copay, and Tier 5 drugs (tobacco cessation products) have a $0 copay. Drugs not listed in the formulary are not covered.
If HealthChoice makes a formulary change that alters your drug’s tier level or increases its cost, we will notify you 60 days before the change so you can review your options.
When Changes Affect a Drug You Currently Take
If you are currently taking a drug that is not listed in the HealthChoice Comprehensive Medicare Formulary, or coverage for your drug has changed; e.g., it has moved to a higher cost-sharing tier, or it has new restrictions, you have a couple of options:
♦♦In some situations, HealthChoice will cover a one-time, temporary supply of your drug when your current supply runs out. This temporary supply is for a maximum of 30 days.
♦♦You and your doctor can find a covered drug that treats your medical condition.
♦♦Your doctor can ask for an exception/prior authorization for your current medication.
Pharmacy Prior Authorization
Prior authorization medications are medications that may be covered under the plan if the prescribed use meets approved guidelines. Prior authorization requests must be submitted by 15
2012 Plan Year
your physician. Please note, HealthChoice may have added or removed certain medications from the list of drugs that require prior authorization.
Quantities of Medications
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations. Some medications have a maximum quantity limitation and/or the medication is not dispensed in a tablet or capsule form. Be aware that quantity limitations may have been added to or removed from some medications for 2012. Also, be aware that under certain circumstances, HealthChoice will make an exception to quantity limitations.
Transition Supply of Medication (Applies Only to Plans With Part D)
During transition to a HealthChoice Part D plan or transition to a formulary medication, you can be authorized to purchase a one-time supply of a non-covered medication. This transition supply, not to exceed a 34-day supply, is available to help you make a successful transition to a HealthChoice Medicare Formulary medication. This temporary supply will be provided, when necessary, prior to initiating or completing the coverage review process for a medication requiring prior authorization. Please note that under certain circumstances, this 34-day supply may be extended. For information on how to obtain a covered transition supply of medication, have your pharmacy contact Medco. See Help Lines on page 41.
Network Pharmacy Access
The HealthChoice Pharmacy Network includes more than 900 pharmacies across Oklahoma and nearly 60,000 pharmacies nationwide. They are called Network Pharmacies because they contract with our Plans to provide covered prescription drugs to members. In most cases, your prescriptions are covered only if they are filled at a Network Pharmacy. Network Pharmacies provide electronic claims processing, so generally, there are no paper claims to file. Sometimes a pharmacy leaves the Network. When this occurs, you will have to get your prescriptions filled at another Network Pharmacy. To locate a HealthChoice Network Pharmacy near you, go to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. Click Find a Provider in the top menu bar and then select HealthChoice Network Pharmacies. You can also contact Medco, 24 hours a day, 7 days a week, at the following numbers:
♦♦Members with Part D call toll-free 1-800-590-6828
♦♦TDD users call toll-free 1-800-716-3231
♦♦Members without Part D call toll-free 1-800-903-8113
♦♦TDD users call toll-free 1-800-825-12302012 Plan Year
16
Non-Network Pharmacy Benefits
Although HealthChoice may cover your covered prescriptions if they are purchased at a non-Network pharmacy, a reduced, non-Network benefit may apply. An exception may be made in the event of an emergency. It is considered an emergency when you:
♦♦Travel outside your plan’s service area and run out of medication, or become ill and need a covered medication and are unable to access a Network Pharmacy
♦♦Cannot get a covered medication within your Plan’s pharmacy network in timely manner
♦♦Fill a prescription for a covered medication that is not regularly stocked at a Network Pharmacy
♦♦Receive a covered medication that is dispensed by a non-Network outpatient facility, such as an emergency room, clinic, or surgery center
If you must use a non-Network pharmacy, you will have to pay the full cost for your prescription and then ask HealthChoice to repay you for its share of the cost. Before you fill a prescription under these circumstances, when possible, check to see if there is a Network Pharmacy in your area by visiting the HealthChoice website at www.sib.ok.gov or healthchoiceok.com. You can also contact Medco at the following numbers:
♦♦Members with Part D call toll-free 1-800-590-6828
♦♦TDD users call toll-free 1-800-716-3231
♦♦Members without Part D call toll-free 1-800-903-8113
♦♦TDD users call toll-free 1-800-825-123017
Medicare Part A (Hospitalization) Services
All benefits are based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except the Part A deductible
100% of the Part A deductible
0%
61st through 90th day
All except the coinsurance per day
The coinsurance per day
0%
91st day and after while using Medicare’s 60 lifetime reserve days
All except the coinsurance per day
The coinsurance per day
0%
Once Medicare’s lifetime reserve days are used, HealthChoice provides additional lifetime reserve days
Limited to 365 days
0%
100%
of Medicare eligible expenses
Certification by HealthChoice is required
0%
Beyond the 365 HealthChoice lifetime reserve days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year.
First 20 days
All approved amounts
0%
0%
21st through 100th day
All except the coinsurance per day
The coinsurance per day
0%
101st day and after
0%
0%
100%
Summary of HealthChoice High and Low Option
Medicare Supplement Plans
2012 Plan YearServices
or Items
Description
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Medicare Part A (Hospitalization) Services ― Continued
2012 Plan Year
18
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Services
or Items
Description
Medicare Part B Pays
HealthChoice Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
The Part B deductible
0%
0%
The Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges in excess of Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%Medicare Part B (Medical) Services ― Continued
Services
or Items
Description
Medicare Part B Pays
HealthChoice Pays
You
Pay
Home Health Care:
Medicare approved services
Medically necessary skilled care and medical supplies
100%
0%
0%
Durable Medical Equipment
The Part B deductible
0%
0%
100%
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
One-time Initial Wellness Physical Exam:
To be completed within 12 months of the day you first enroll in Medicare Part B
All Medicare beneficiaries
80%
No Part B deductible
20%
No Part B deductible
0%
2012 Plan Year
19
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive
Services
Who is
Covered
Medicare
Pays
HealthChoice Pays
You Pay
Screening Mammogram:
Once every
12 months
All female Medicare beneficiaries age 40 and older
80%
No Part B deductible
20%
No Part B deductible
0%Preventive
Services
Who is
Covered
Medicare
Pays
HealthChoice Pays
You Pay
Screening Blood Tests for Early Detection of Cardiovascular (Heart) Disease
All Medicare beneficiaries
100%
0%
0%
Pap Test and Pelvic Exam:
Once every 24 months; includes a clinical breast exam
Once every 12 months if high risk/abnormal Pap test in preceding 36 months
All female Medicare beneficiaries
Pap Test, 100% No Part B deductible
For all other exams, 80%
No Part B deductible
0%
For all other exams, 20%
No Part B deductible
0%
Diabetes Screening Test
All Medicare beneficiaries at risk for diabetes
100%
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes
80% after the Part B deductible
20% after the Part B deductible
0%
Diabetes Monitoring: Includes coverage for glucose monitors, test strips, and lancets
All Medicare beneficiaries with diabetes – must be requested by your doctor
80% after the Part B deductible
20% after the Part B deductible
0%
Bone Mass Measurements: Once every 24 months for qualified individuals
All Medicare beneficiaries at risk for losing bone mass
80% after the Part B deductible
20% after the Part B deductible
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
20Preventive
Services
Who is
Covered
Medicare
Part B Pays
HealthChoice Pays
You Pay
Glaucoma Screening: Once every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of their practice
Medicare beneficiaries at high risk or a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to once every 12 months
Flexible
Sigmoidoscopy:
Limited to once every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to once every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
There is no minimum age for having a colonoscopy
For the fecal occult blood test, 100%
No Part B deductible
For all other tests, 80% after the Part B deductible
0% for the fecal occult blood test
For all other tests, 20% after the Part B deductible
0%
0%
Note: For a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare Approved Amount
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
21
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare Approved Amount.Preventive
Services
Who is Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Prostate Cancer Screening
Digital Rectal Exam: Once every 12 months
Prostate Specific Antigen Test (PSA): Once every 12 months
All male Medicare beneficiaries age 50 and older
For the digital rectal exam, 80% after the Part B deductible
For the PSA test, 100%
No Part B deductible
For the digital rectal exam, 20% after the Part B deductible
0% for the PSA test
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
22
Preventive Services — Vaccinations
Flu Vaccination:
One per flu season
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Hepatitis B
Vaccination:
Medicare beneficiaries at medium to high risk for Hepatitis B
For members with Part D, the vaccine and administration are covered under the HealthChoice pharmacy benefit.
For members without Part D, the vaccine and administration are covered under the Medicare Part B benefit.
For Services Not Covered by Medicare
Services
Benefits
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for
foreign travel
exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 each calendar year, then 20%
All amounts over the $50,000 lifetime maximum
No Medicare deductible2012 Network Pharmacy Benefits
HealthChoice High Option Medicare Supplement Plans
With and Without Part D
2012 Plan Year
23
THIS CHART SHOWS NETWORK BENEFITS
There is no annual deductible and no Coverage Gap. There is an annual out-of-pocket maximum. Discounts apply after $2,930 in total drug spend.
Prescription
Medications
Medicare
Pays
HealthChoice
Pays
You
Pay
Generic (Tier 1) or Preferred (Tier 2) drugs costing $100 or less
$0
Allowed Charges after your copay
Copay up to $30 maximum
Generic (Tier 1) or Preferred (Tier 2) drugs costing more than $100
$0
Allowed Charges after your copay
Copay of 25% up to $60 maximum
Non-Preferred (Tier 3) drugs costing $100 or less
$0
Allowed Charges after your copay
Copay up to $60 maximum
Non-Preferred (Tier 3) drugs costing more than $100
$0
Allowed Charges after your copay
Copay of 50% up to $120 maximum
Preferred, high cost or specialty (Tier 4) drugs
$0
Allowed Charges after your copay
Copay is based on the quantity of medication
Preferred,(Tier 5) tobacco cessation prescription drugs
$0
Allowed Charges
$0 copay
DISCOUNTS AFTER DRUG SPEND REACHES $2,930
Once total drug spend reaches $2,930, a 50% discount is applied to the copay for brand-name drugs.
THE PHARMACY OUT-OF-POCKET MAXIMUM
Out-of-Pocket Maximum
After Out-of-Pocket is Met
The annual out-of-pocket maximum is $4,700.
Only copays for covered prescription drugs purchased at Network Pharmacies apply to the out-of-pocket maximum. See the chart above for copay amounts.
After your pharmacy out-of-pocket costs reach $4,700, HealthChoice pays 100% of Allowed Charges for covered prescription drugs purchased at Network Pharmacies for the remainder of the calendar year.
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limits.THE CHART BELOW SHOWS NETWORK BENEFITS
Annual
Deductible
$320
Initial
Coverage Limit
$2,610
Coverage
Gap
$3,727.50
Annual Out-of-Pocket Maximum
$4,700
You pay 100% of $320
After the deductible, you and HealthChoice share the costs of the next $2,610 of prescription drug costs.
You pay 25% ($652.50) and
HealthChoice pays 75% ($1,957.50).
You pay 100% of the next $3,727.50 of prescription drug costs.
After you spend $4,700 out-of-pocket, HealthChoice pays 100% of Allowed Charges for covered prescription drugs for the remainder of the calendar year.
REACHING THE ANNUAL OUT-OF-POCKET MAXIMUM OF $4,700
$ 320.00 Deductible
$ 652.50 25% of the Initial Coverage Limit of $2,610
$3,727.50 Coverage Gap – you pay 100% of costs for prescription drugs
$4,700.00 Your total annual out-of-pocket for covered prescription drugs
YOUR COSTS FOR COVERED MEDICATIONS
You Pay
HealthChoice Pays
Annual deductible of $320
$0
$652.50 (25%) of the next $2,610 of prescription drug costs, the Initial Coverage Limit.
$1,957.50 (75%) of the next $2,610.
During the Coverage Gap, you are responsible for the next $3,727.50 of prescription drug costs; however, you receive a 50% discount on the cost of brand-name drugs and a 14% discount on the cost of generic drugs.
HealthChoice pays the 14% discount on the cost of generic drugs during the Coverage Gap.
$0 after you have spent $4,700 out-of-pocket for prescription drugs.
100% of Allowed Charges for covered drugs for the remainder of the calendar year.
2012 Plan Year
24
2012 Network Pharmacy Benefits for
HealthChoice Low Option Medicare Supplement Plans
With and Without Part D
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater, not to exceed the FDA approved ‘usual’ dosage for a 100-day supply. Specific therapeutic categories, medications, and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.25
2012 Plan Year
Section III
UnitedHealthcare
Senior Supplement PlansUnitedHealthcare Senior Supplement High and Low Option Plans
Medicare Part A (Hospitalization) Services
All Benefits are based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part A Pays
UnitedHealthcare Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except the Part A deductible
100% of the
Part A deductible
0%
61st through 90th day
All except the coinsurance per day
The coinsurance per day
0%
91st day and after while using Medicare’s 60 lifetime reserve days
All except the coinsurance per day
The coinsurance per day
0%
Once Medicare’s lifetime reserve days are used, UnitedHealthcare provides additional lifetime reserve days
Limited to 365 days
0%
100% of Medicare eligible expenses
Certification is required
0%
Beyond the 365 UnitedHealthcare lifetime reserve days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year.
First 20 days
All approved amounts
0%
0%
21st through 100th day
All except the coinsurance per day
The coinsurance per day
0%
101st day and after
0%
0%
100%
2012 Plan Year
26Services
or Items
Description
Medicare
Part A Pays
UnitedHealthcare Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Medicare Part A (Hospitalization) Services ― Continued
2012 Plan Year
27
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Services
or Items
Description
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
The Part B deductible
0%
0%
The Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges in excess of Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%Medicare Part B (Medical) Services ― Continued
Services
or Items
Description
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Home Health Care:
Medicare Approved Services
Medically necessary skilled care and medical supplies
100%
0%
0%
Durable Medical Equipment
Part B deductible
0%
0%
100%
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
One-time Initial Wellness Physical Exam:
To be completed within 12 months of the day you first enroll in Medicare Part B
All Medicare beneficiaries
80%
No Part B deductible
20%
No Part B deductible
0%
2012 Plan Year
28
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive
Services
Who is
Covered
Medicare
Pays
UnitedHealthcare Pays
You Pay
Screening Mammogram:
Once every 12 months
Female Medicare beneficiaries age 40 and older
80%
No Part B deductible
20%
No Part B deductible
0%Preventive
Services
Who is
Covered
Medicare
Pays
UnitedHealthcare Pays
You Pay
Screening Blood Tests for Early Detection of Cardiovascular (Heart) Disease
All Medicare beneficiaries
100%
0%
0%
Pap Test and Pelvic Exam:
Once every 24 months; includes a clinical breast exam
Once every 12 months if high risk/abnormal Pap test in preceding 36 months
Female Medicare beneficiaries
Pap Test, 100% No Part B deductible
For all other exams, 80%
No Part B deductible
0%
For all other
exams, 20%
No Part B deductible
0%
0%
Diabetes Screening Test
All Medicare beneficiaries at risk for diabetes
100%
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes
80% after the Part B deductible
20% after the Part B deductible
0%
Diabetes Monitoring:
Includes coverage for glucose monitors, test strips, and lancets
All Medicare beneficiaries with diabetes – must be requested by your doctor
80% after the Part B deductible
20% after the Part B deductible
0%
Bone Mass Measurements:
Once every 24 months for qualified individuals
Medicare beneficiaries at risk for losing bone mass
80% after the Part B deductible
20% after the Part B deductible
0%
Medicare Part B (Preventive) Services ― Continued
2012 Plan Year
29Preventive
Services
Who is
Covered
Medicare
Part B Pays
UnitedHealthcare Pays
You
Pay
Glaucoma Screening: Once every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of his/her practice
Medicare
beneficiaries at high risk or a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to once every 12 months
Flexible
Sigmoidoscopy:
Limited to once every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to once every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
There is no minimum age for having a colonoscopy
For the fecal occult blood test, 100%
No Part B deductible
For all other tests, 80% after the Part B deductible
0% for the fecal occult blood test
For all other tests, 20% after the Part B deductible
0%
0%
Note: For a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare Approved Amount
2012 Plan Year
Medicare Part B (Preventive) Services ― Continued
30
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare Approved Amount.Medicare Part B (Preventive) Services ― Continued
Preventive
Services
Who is
Covered
Medicare
Part B Pays
UnitedHealthcare
Pays
You
Pay
Prostate Cancer Screening
Digital Rectal Exam: Once every 12 months
Prostate Specific Antigen (PSA) Test: Once every 12 months
All male Medicare beneficiaries age 50 and older
For the digital rectal exam, 80% after the Part B deductible
For the PSA test, 100% No Part B deductible
For the digital rectal exam, 20% after the Part B deductible
0% for the PSA test
0%
0%
2012 Plan Year
Preventive Services - Vaccinations
Flu Vaccination:
One per flu season
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
For all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment.
Hepatitis B Vaccination:
Medicare beneficiaries at medium to high risk for Hepatitis B
The vaccine and administration are covered under the pharmacy benefit.
Services Not Covered by Medicare
Services
Benefits
Medicare
Part B Pays
UnitedHealthcare Pays
You Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for foreign travel exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 each calendar year, then 20%
Amounts over the $50,000 lifetime maximum
31Prescription
Medications
You
Pay
Tier 1 — Preferred Generics
$10
Tier 2 — Preferred Brand
$30
Tier 3 — Non-Preferred
$60
Tier 4 — Specialty
33%
UnitedHealthcare Senior Supplement High and Low Option Plans — You pay the applicable copays of $10 for Tier 1 prescriptions, $30 for Tier 2 prescriptions, and $60 for Tier 3 prescriptions. For prescriptions in the Specialty Tier, you pay 33% of the discounted network price. You can find a complete formulary listing on www.UnitedhealthRxforGroups.com. If the formulary changes, you will be notified in writing before the change. Only Medicare Part D covered drugs will impact your Medicare prescription drug plan annual out-of-pocket spending.
Certain prescription drugs have maximum quantity limits. Your provider must get prior authorization from UnitedHealthcare for certain prescription drugs.
Once you are out-of-pocket $2,930 (the Initial Coverage Limit) in copays and/or specialty prescriptions, you are responsible for 100% of the discounted network price for all prescriptions except for Tier 1 drugs. After you are out-of-pocket $4,700, you pay 5% or a minimum of $2.60 for generics and a minimum of $6.50 for brand-name prescriptions.
Additionally, a mail order benefit is available. You can receive a 90-day supply of prescriptions for two copays. The coverage, during and after the gap, also applies.
2012 Plan Year
UnitedHealthcare Senior Supplement
High and Low Option Plans
Prescription Drug Coverage
322012 Plan Year
33
Section IV
Dental and Vision
Plan Options2012 Plan Year
34
Comparison of Benefits For Dental Plans
Your Costs for Network Services
HealthChoice
Dental
CIGNA Dental Care
Plan (Prepaid)
Assurant
Freedom
Preferred
ANNUAL
DEDUCTIBLE
Network: $25 Basic and Major services combined
Non-Network: $25 Preventive, Basic, and Major services combined
No deductible or plan maximum
$5 office copay applies
$25 per person, per calendar year, waived for preventive services in-network
PREVENTIVE CARE
Cleanings, routine oral exams
Allowed Charges apply
Network: $0
Non-Network: $0 of Allowed Charges after deductible
Sealant: $15 per tooth
No charge for routine cleaning once every 6 months
No charge for topical fluoride application (through age 18)
No charge for periodic oral evaluations
$0 with no deductible when in-network
BASIC CARE
Extractions, oral surgery
Allowed Charges apply
Network: 15%
Non-Network: 30%
Deductible applies
Amalgam: One surface, permanent teeth $21
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and customary when in-network,
Deductible applies
MAJOR CARE
Dentures, bridge work
Allowed Charges apply
Network: 40%
Non-Network: 50%
Deductible applies
Root canal, anterior: $355
Periodontal/scaling/root planing 1-3 teeth (per quadrant): $71
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and customary when in-network
Deductible applies
All plan changes are indicated by bold text.2012 Plan Year
35
Comparison of Benefits For Dental Plans
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental
PPO — POS
In-Network and Out-of-Network
Delta Dental Premier
In-Network and Out-of-Network
Delta’s Choice
PPO
PPO Network
No deductibles
$25 per person, per year applies to Basic and Major Care only
$50 per person, per year applies to diagnostic, Preventive, Basic, and Major Care
$100 per person, per year applies to Major Care only (Level 4)
No charge for routine cleaning (once every 6 months)
No charge for topical fluoride application (up to age 18)
No charge for periodic oral evaluations
$0 of allowable amounts
No deductible applies
Includes diagnostic
$0 of allowable amounts after deductible
Includes diagnostic
Schedule of covered services and copays. Copay examples:
Routine cleaning $5
Periodic oral evaluation $5
Topical fluoride application (up to age 19) $5
Includes diagnostic
Fillings
Minor oral surgery
Refer to the copayment schedule for each plan
15% of allowable amounts after deductible
30% of allowable amounts after deductible
Schedule of covered services and copays Copay example:
Amalgam - one surface, primary or permanent tooth $12
Root canal
Periodontal
Crowns
Refer to the copayment schedule for each plan
40% of allowable amounts after deductible
50% of allowable amounts after deductible
Schedule of covered services and copays Copay examples:
Crown - porcelain/ceramic substrate $241
Complete denture - maxillary $3202012 Plan Year
36
Comparison of Benefits For Dental Plans
Your Costs for Network Services
HealthChoice
Dental
CIGNA Dental Care Plan (Prepaid)
Assurant
Freedom
Preferred
ORTHODONTIC CARE
Allowed Charges apply
Network: 50%
Non-Network: 50%
12-month waiting period may apply
No lifetime orthodontic maximum for Network or non-Network
Covered for members under age 19 and members age 19 and older with TMD
$2,280 out-of-pocket for children through age 18
$3,120 out-of-pocket for adults
24-month treatment excludes orthodontic treatment plan and banding
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime maximum for members under age 19
12-month waiting period may apply
PLAN YEAR MAXIMUM
Network and non-Network $2,000 per person, per year
No maximum
$2,000
FILING CLAIMS
Network: No claims to file
Non-Network: You file claims
No claims to file
Member/provider must file claims
All plan changes are indicated by bold text.2012 Plan Year
37
Comparison of Benefits For Dental Plans
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental
PPO — POS
In-Network and Out-of-Network
Delta Dental Premier
In-Network and Out-of-Network
Delta’s Choice
PPO
PPO Network
25% discount
Orthodontic benefits are available to eligible adults and dependent children
40% of allowable amounts, up to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
40% of allowable amounts, up to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
You pay amounts in excess of $50 per month
Lifetime maximum up to $1,800
No deductible
No waiting period
Orthodontic benefits are available to the employee and their lawful spouse and eligible dependent children
No annual maximum for general dentist
$2,500 per person, per year
$3,000 per person, per year
$2,000 per person, per year
No claims to file
Claims are filed by participating dentists
Claims are filed by participating dentists
Claims are filed by participating dentists2012 Plan Year
Comparison of Benefits for Vision Plans
38
Humana/CompBenefits
VisionCare Plan
Primary Vision
Care Services, Inc.
Covered Services
In-Network
Out-of-
Network
In-Network
Out-of-
Network
Eye
Exams
$10 copay
One per year
No copay; Plan pays up to $35; One per year
$0 copay
No limit on exams
Plan pays up to $40; One per year
Lenses
Each Pair
$25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%)
A discount applies to progressive lenses
One pair per year
Plan pays up to:
$25 single
$40 bifocals
$60 trifocals
$100 lenticular
One per year
You pay wholesale cost with no limit on number of pairs
You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames One per year
Frames
$25 material copay applies to lenses and/or frames;
$45 wholesale frame allowance;
One pair per year
$25 copay
Plan pays up to $45
One pair per year
You pay wholesale cost with no limit on number of pairs
You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
One per year
Contact Lenses
$130 allowance for conventional or disposable lenses and fitting fee in lieu of all other benefits
Medically necessary, Plan pays 100%
One set per year
$130 allowance for exam, contacts, and fitting fee in lieu of all other benefits
Medically necessary
Plan pays $210
One set per year
You pay wholesale cost for contacts
$50 fee applies to all soft contact lens fittings; $75 to rigid or gas permeable lens fittings; $150 to hybrid contact lens fittings Replacement lenses do not have these fees
Limit of one set annually in lieu of eyeglasses You pay normal doctor’s fees, reimbursed up to $60
Laser
Vision Correction
$895 copay conventional
$1,295 copay custom
$1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
No benefit
Discount nationwide at The Laser Center (TLC)
No benefit
All plan changes are indicated by bold text.2012 Plan Year
Comparison of Benefits for Vision Plans
39
Superior Vision Plan
UnitedHealthcare Vision
Vision Service Plan (VSP)
In-Network
Out-of-
Network
In-Network
Out-of-
Network
In-Network
Out-of-
Network
$10 copay
One per year
OD-$26 max
MD-$34 max
$10 copay
One per year
Plan pays up to $40
$10 copay
One per year
$10 copay; Plan pays up to $35
$25 copay
One pair per year
Plan pays up to:
$26 single
$39 bifocals
$49 trifocals
$78 lenticular
$25 copay
One pair per year
Lens options covered in full include:
• UV coating
• Tints
Plan pays up to:
$40 single
$60 bifocals
$80 trifocals
$80 lenticular
$25 annual material copay
One set per year
Polycarbonate lenses covered in full for dependent children
35-40% savings on non-covered lens options
$25 annual material copay
Plan pays up to:
$25 single
$40 bifocals
$55 trifocals
$80 lenticular
$25 copay
Plan pays up to $125
One pair per year
Plan pays up to $68
$25 copay
$130 allowance
One pair per year
Plan pays up to $45
$25 annual material copay
$120 allowance
20% off any out-of-pocket costs above the allowance
One pair per year
$25 annual material copay
Plan pays up to $45
$25 standard fitting copay
After copay, Plan pays 100%
$25 specialty fitting copay
After copay, Plan pays up to $50 Plan pays up to $120 for elective contacts
Medically necessary contacts are covered in full (in lieu of glasses)
Fitting fee is not a covered benefit
$0 copay
Plan pays up to $100
For medically necessary contacts, Plan pays up to $210
(in lieu of glasses)
$25 copay covers fitting/evaluation fees, contacts (including disposables), and up to 2 follow-up visits
(in lieu of glasses)
Plan pays up to $150
For medically necessary contacts, Plan pays up to $210
(in lieu of glasses)
$0 copay
$120 allowance applies to the cost of contact lens exam and contact lenses
15% discount on contact lens exam (in lieu of glasses)
Contact lens exam covered in full after a copay of up to $60
$0 copay
Plan pays up to $105 for disposable or conventional contact lenses
(in lieu of glasses)
20 to 50% savings on LASIK surgery
No benefit
Access to
discounted refractive eye surgery from provider locations in the U.S.
No benefit
Laser vision correction services at a reduced cost through VSP’s contracted laser surgery centers
No benefitNotes
2012 Plan Year
4041
2012 Plan Year
Dental Plans’ Help Lines
Assurant, Inc. Dental
Prepaid Plan, toll-free
1-800-443-2995
Indemnity Plan, toll-free
1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Dental Care Plan (Prepaid)
Toll-free
1-800-244-6224
Toll-free Relay Service
1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area
1-405-607-2100
Toll-free
1-800-522-0188
Website: www.deltadentalok.org
Vision Plans’ Help Lines
Humana/CompBenefits VisionCare Plan
Toll-free
1-800-865-3676
Toll-free TDD
1-877-553-4327
Website
www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
Toll-free
1-888-357-6912
Toll-free TDD
1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
Toll-free
1-800-507-3800
Toll-free TDD
1-916-852-2382
Website www.superiorvision.com
UnitedHealthcare Vision
Toll-free
1-800-638-3120
Toll-free TDD
1-800-524-3157
Website www.myuhcvision.com
Vision Service Plan (VSP)
Toll-free
1-800-877-7195
Toll-free TDD
1-800-428-4833
Website www.vsp.com
Health Plans’ Help Lines
HealthChoice
Health, Dental, and Life Claims, ID Cards, Benefits and Verification of Coverage
Oklahoma City Area
1-405-416-1800
Toll-free
1-800-782-5218
TDD Oklahoma City
1-405-416-1525
Toll-free TDD
1-800-941-2160
Website www.sib.ok.gov or
www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
Plans With Part D:
Toll-free
1-800-590-6828
Toll-free TDD
1-800-716-3231
Plans Without Part D:
Toll-free
1-800-903-8113
Toll-free TDD
1-800-825-1230
Certification
Toll-free
1-800-848-8121
Toll-free TDD
1-877-267-6367
Member Services and Provider Directory
Oklahoma City Area
1-405-717-8780
Toll-free
1-800-752-9475
TDD Oklahoma City
1-405-949-2281
Toll-free TDD
1-866-447-0436
UnitedHealthcare
Senior Supplement Plans
Toll-free
1-800-851-3802
Toll-free TYY 1-800-851-3802, ext 711
Website www.UHCRetiree.com
If a plan does not list aTDD or TTY number, members should use a relay service to contact the plan.